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.
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Related Questions
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.
Correct Answer is A
Explanation
A) Taping all connections within the system. Taping all connections helps prevent air leaks, which can compromise the function of the chest drainage system.
B) Turning on suction to 35 cm. Suction levels are typically set between 10 to 20 cm of water pressure. 35 cm is excessive and may cause lung tissue damage.
C) Keeping the system at the level of the patient's chest. The drainage system should always be kept below the level of the chest to promote gravity drainage and prevent backflow.
D) Looping the tubing between the mattress and the bed rail to minimize length. Tubing should not be looped or kinked, as this can obstruct drainage and compromise system function.
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