A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck.

Suction for 20 seconds.

Clean secretions from the tube using hydrogen peroxide.

Set the vacuum pressure at 120 mmHg for suctioning.

Answer and Explanation

The Correct Answer is D

A) Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. The ties should be secure but loose enough to fit one finger between the ties and the neck to prevent skin breakdown and maintain comfort.
B) Suction for 20 seconds. Suctioning for 20 seconds is too long and may cause hypoxia. Suction should not exceed 5 to 10 seconds.
C) Clean secretions from the tube using hydrogen peroxide. Hydrogen peroxide can irritate the delicate tissues and is not recommended. Saline or prescribed cleaning agents are preferred.
D) Set the vacuum pressure at 120 mmHg for suctioning. For a toddler, suction pressure should typically be between 80 and 120 mmHg to prevent mucosal damage.

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Correct Answer is C

Explanation

A. Examining the character of the sputum: While monitoring secretions is important, it does not necessarily indicate the need for immediate suctioning.
B. Monitoring the rate of respirations: An increased respiratory rate can indicate distress but is not a definitive cue for suctioning.
C. Auscultating the breath sounds: This helps identify the presence of secretions or airway obstruction and is a primary indicator for suctioning.
D. Determining the last time the patient was suctioned: Suctioning should be based on clinical need rather than a routine schedule.

A. jaundiced B. febrile C. obese D. dark skinned

Correct Answer is A

Explanation

A. Jaundiced: The yellow discoloration of the skin can interfere with light absorption, affecting the accuracy of the reading.
B. Febrile: An elevated body temperature does not affect the pulse oximeter's accuracy.
C. Obese: Subcutaneous fat does not interfere with the device's light absorption or reading accuracy.
D. Dark-skinned: Higher melanin levels can affect the absorption of light, leading to less accurate readings.

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A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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