Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?
Correct Answer: C
Rationale: In this scenario, suctioning the tracheostomy tube is the most appropriate action. The decline in oxygen saturation and signs of anxiety may indicate mucus obstruction, which suctioning can alleviate, improving airflow and oxygenation.
Obtaining arterial blood gases (A) is important for assessing respiratory status but does not provide immediate relief for the infant's distress. Increasing the oxygen rate (B) may not address the underlying cause of the low saturation, which could worsen if there's an obstruction. Medicating for anxiety and pain (D) does not resolve the potential airway issue and could further complicate the infant's respiratory status.