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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.
Correct Answer is B
Explanation
A. Removing any adhesive from the patient's skin with acetone: Acetone is highly flammable and should not be used near oxygen equipment.
B. Assessing equipment in room for frayed cords: Frayed cords can cause electrical sparks, which may ignite in an oxygen-rich environment.
C. Reducing humidification on the oxygen delivery device: Humidification is essential to prevent mucosal dryness; reducing it unnecessarily can cause airway irritation.
D. Using clothing of synthetic cloth for the patient: Synthetic materials generate static electricity, which can ignite in the presence of oxygen. Cotton clothing is preferred.
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