A nurse is planning to perform tracheostomy care for a toddler.
which of the following is an appropriate action for nurse to take?
use clean technique to change the tracheostomy tube.
clean around the stoma with full -strength hydrogen peroxide.
Place the child in Trendelenburg position when performing care.
Have the child flex his head when securing the ties.
The Correct Answer is D
The correct answer is D. Have the child flex his head when securing the ties.
Explanation:
When securing tracheostomy ties, flexing the head helps ensure the ties are snug but not too tight. This minimizes the risk of accidental dislodgement while allowing proper airway support.
Why the other options are incorrect:
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A. Use clean technique to change the tracheostomy tube – Incorrect. Sterile technique is required when changing the tracheostomy tube to prevent infection, especially in pediatric clients.
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B. Clean around the stoma with full-strength hydrogen peroxide – Incorrect. Diluted hydrogen peroxide or saline is recommended to avoid tissue irritation. Full-strength hydrogen peroxide can damage delicate skin around the stoma.
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C. Place the child in Trendelenburg position when performing care – Incorrect. The Trendelenburg position (head down, feet up) is not used for tracheostomy care and can increase the risk of aspiration or breathing difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceB.
Choice A rationale:
Dark brown blood in emesis is typically old blood and may not require immediate intervention.However, it should still be monitored and reported to the healthcare provider.
Choice B rationale:
Frequent swallowing can indicate active bleeding from the surgical site, which requires immediate intervention.This is a sign that the child may be swallowing blood, which can lead to significant blood loss.
Choice C rationale:
An axillary temperature of 38°C (100°F) is a mild fever and not uncommon postoperatively.It should be monitored, but it does not require immediate intervention.
Choice D rationale:
A pain level of 5 on the FACES scale indicates moderate pain, which is expected after a tonsillectomy.Pain management should be addressed, but it does not require immediate intervention.
Correct Answer is B
Explanation
Choice A rationale
Consuming flavored yogurt instead of plain yogurt may not be beneficial for a lactose intolerant individual. Flavored yogurts often contain added sugars and may still contain lactose, which can trigger symptoms in individuals with lactose intolerance.
Choice B rationale
Replacing milk with non-dairy sources of calcium is a common strategy for managing lactose intolerance. Non-dairy sources of calcium include foods like broccoli, oranges, almonds, tofu, and certain fortified products. This can help ensure the individual meets their calcium needs without triggering symptoms of lactose intolerance.
Choice C rationale
Drinking milk on an empty stomach is not typically recommended for individuals with lactose intolerance. Consuming lactose-containing foods or drinks on an empty stomach may increase the likelihood of experiencing symptoms.
Choice D rationale
The tolerance for plain milk versus chocolate milk can vary among individuals with lactose intolerance. However, chocolate milk often contains added sugars and may still contain lactose, which can trigger symptoms.
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