What is an important nursing consideration when suctioning a young child who has had heart surgery?
Expect symptoms of respiratory distress when suctioning.
Administer supplemental oxygen before and after suctioning.
Perform suctioning at least every hour.
Suction for no longer than 30 seconds at a time.
The Correct Answer is B
The correct answer is choice B. Administer supplemental oxygen before and after suctioning.
Choice A rationale:
Expect symptoms of respiratory distress when suctioning. While respiratory distress can occur during and after suctioning, it is not the main nursing consideration. The primary goal is to minimize any potential complications and ensure the child's safety during the procedure, which can be achieved by following appropriate guidelines.
Choice B rationale:
Administer supplemental oxygen before and after suctioning. Correct Answer. Administering supplemental oxygen before and after suctioning is crucial to maintain adequate oxygenation during and after the procedure. Suctioning can temporarily decrease oxygen levels and cause desaturation, especially in a child who has undergone heart surgery. Providing supplemental oxygen helps prevent hypoxia and supports respiratory function.
Choice C rationale:
Perform suctioning at least every hour. Frequent suctioning at least every hour is not a standard nursing practice, especially for a child who has had heart surgery. Suctioning should only be performed as needed based on the child's clinical condition, and excessive suctioning can irritate the airway and lead to complications.
Choice D rationale:
Suction for no longer than 30 seconds at a time. While limiting the duration of suctioning is important to prevent hypoxia and trauma to the airway, the specific duration of 30 seconds is not a universal rule. Suctioning should be performed for the shortest effective duration to minimize the risk of complications, but the optimal time can vary based on the child's condition and the type of suctioning being used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Explain in simple terms how it works.
Choice A rationale:
Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.
Choice B rationale:
Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.
Choice C rationale:
Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.
Choice D rationale:
Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.
Correct Answer is B
Explanation
The correct answer is Choice B: Dry skin.
Choice A rationale:
Diarrhea is not a common clinical manifestation of juvenile hypothyroidism. Hypothyroidism is characterized by an underactive thyroid gland, leading to a decrease in metabolic activity. Symptoms of hypothyroidism include fatigue, weight gain, cold intolerance, constipation, and dry skin, but not diarrhea.
Choice B rationale:
Dry skin is a common clinical manifestation of juvenile hypothyroidism. The decreased thyroid function results in a slower metabolic rate, which can lead to dry and coarse skin due to reduced oil production. This symptom is often seen in hypothyroid patients.
Choice C rationale:
Insomnia is not a common clinical manifestation of juvenile hypothyroidism. Hypothyroidism usually leads to fatigue and excessive sleepiness rather than insomnia.
Choice D rationale:
Accelerated growth is not a common clinical manifestation of juvenile hypothyroidism. In fact, the opposite is true. Hypothyroidism in children can lead to growth retardation due to the decreased metabolic rate and altered hormonal balance.
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