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 A

Explanation

A. Sitting upright and forward with arms supported on an over-the-bed table: This tripod position allows for maximum lung expansion by reducing pressure on the diaphragm and improving airflow, especially for patients with chronic obstructive pulmonary disease (COPD).
B. Semi-Fowler's position with a single pillow behind the head: This position does not optimize lung expansion as well as the tripod position.
C. High Fowler's position without a pillow behind the head: Although better than lying flat, this position lacks arm support, which helps in leveraging accessory muscles for breathing.
D. Right lateral with the head of the bed elevated 45 degrees: This position is not beneficial for promoting effective lung expansion in patients with emphysema.

A. "It delivers a specific concentration of oxygen constantly." B. "It allows you to remove it for a while when it gets uncomfortable." C. "It delivers the highest concentration of oxygen possible." D. "It delivers the low concentration of oxygen you need."

Correct Answer is D

Explanation

A) "It delivers a specific concentration of oxygen constantly." A nasal cannula does not provide a constant or precise concentration of oxygen, as it is influenced by the client's breathing pattern.
B) "It allows you to remove it for a while when it gets uncomfortable." Removing the nasal cannula intermittently may disrupt oxygen therapy and decrease oxygen saturation.
C) "It delivers the highest concentration of oxygen possible." A nasal cannula delivers low-flow oxygen and does not provide the highest possible oxygen concentration.
D) "It delivers the low concentration of oxygen you need." A nasal cannula is designed for clients who need a low concentration of oxygen, typically between 1 to 6 liters per minute.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

Correct Answer is A

Explanation

A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?

Correct Answer is D

Explanation

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