69. A nurse prepares to suction the tracheostomy tube of a 15-month-old child. What steps should the nurse take in completing this procedure? Select all that apply.
69. A nurse prepares to suction the tracheostomy tube of a 15-month-old child. What steps should the nurse take in completing this procedure? Select all that apply.
. Select vacuum pressure between 60 and 100 mm Hg.
. Suction for 10 seconds.
. Insert suction catheter so that the tip passes beyond the carina.
. Wash hands.
. Hyperventilate the child with 100% oxygen via resuscitation bag.
. Remove sterile 8- or 10-French suction catheter from package.
Test-Taking Tip
Pay close attention to the age of the client in the question stem. A 15-month-old child requires less vacuum pressure and a smaller catheter than an older child or adult.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Therapeutic Procedures
. . . .
Answer 1 is correct because the nurse should select the appropriate amount of suction, which is between 60 and 100 mm Hg. Selecting less suction would not remove secretions and applying greater than 100 mm Hg of suction may cause trauma to the tissues. Answer 2 is incorrect because the child should be suctioned for no longer than 5 seconds. Answer 3 is incorrect because the tip of the suction catheter should be inserted no further than the end of the tracheostomy tube, or to a maximum of 0.5 cm past the end of the tube. Inserting the catheter past the carina could damage the tracheobronchial wall, sending the catheter down one side of the bronchial tree. Answer 4 is correct because the nurse should first wash hands to prevent infection. Answer 5 is correct because the nurse should oxygenate the child prior to suctioning and immediately after suctioning. Answer 6 is correct because the nurse should remove the catheter from the package and have it ready for suctioning. Additionally, the nurse should select a small catheter for suctioning, such as an 8 or 10 French.