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 A
Explanation
A. Oxygen diffuses across the alveolar membrane into the blood: This is the primary function of the respiratory system, ensuring oxygenation of blood.
B. The alveoli have cilia that help remove foreign particles: Cilia are present in the respiratory tract, but not in the alveoli.
C. The diaphragm controls respiration: The diaphragm assists with breathing but does not "control" respiration, which is regulated by the brainstem.
D. The bronchioles contain macrophages that phagocytize inhaled bacteria: Macrophages are found in alveoli, not the bronchioles.
Correct Answer is A
Explanation
A) A nonrebreather mask should fit snugly over a client's face. A proper fit ensures effective oxygen delivery and prevents room air from entering the mask.
B) The reservoir bag on a nonrebreather mask should collapse with exhalation. The reservoir bag should not completely collapse. If it does, the oxygen flow may be inadequate.
C) A nonrebreather mask dries a client's mucous membranes. While high-flow oxygen delivery systems can dry mucous membranes, this is not specific to non rebreather masks.
D) Use a non rebreather mask to deliver low-flow oxygen. Non rebreather masks are designed to deliver high concentrations of oxygen (typically 60% to 100%).
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