A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions.
When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Leave the old ties in place until the new ones are secure.

Secure tracheostomy ties by making knots close to the tube.

Remove ties to secure a disposable, soft foam collar with self-adhesive fastening.

Place knots of the ties laterally to prevent irritation and pressure.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Maintains airway patency: Leaving the old ties in place until the new ones are secure ensures that the tracheostomy tube remains in the correct position and prevents accidental decannulation, which could obstruct the airway and lead to respiratory distress or arrest. This is the most important priority in tracheostomy care.

Prevents tube displacement: Accidental decannulation can occur during tie changes, especially in patients with copious secretions or who are restless or agitated. Keeping the old ties in place acts as a safety measure to keep the tube in position even if the new ties are not immediately secured.

Allows for adjustments: If the new ties are not tied correctly or are too tight, the old ties can be loosened or removed to make adjustments without compromising the airway.

Minimizes anxiety: Leaving the old ties in place can help to reduce anxiety in patients who are apprehensive about the tie- changing process, as it provides a sense of security and ensures that the tube will not be dislodged.

Choice B rationale:

Increases risk of skin irritation: Knots tied close to the tube can rub against the skin, causing irritation, discomfort, and potential skin breakdown, especially in patients with sensitive skin or who have copious secretions.

Impinges on blood flow: Tight knots can also constrict blood vessels, potentially impairing circulation to the skin around the tracheostomy site.

Difficult to remove in emergencies: Knots tied too close to the tube can be challenging to untie quickly in case of an emergency, such as accidental decannulation or the need to suction secretions.

Choice C rationale:

Not appropriate for all patients: Disposable, soft foam collars with self-adhesive fastening may not be suitable for patients with copious secretions, as the adhesive may not adhere well to moist skin.

May not provide adequate support: These collars may not provide the same level of support as traditional tracheostomy ties, especially in patients with active neck movement or who are at risk of accidental decannulation.

Potential for skin irritation: The adhesive on the collar can also irritate the skin around the tracheostomy site in some patients.

Choice D rationale:

May not prevent irritation: Placing knots laterally may not completely eliminate the risk of skin irritation, as the ties can still rub against the skin with neck movement or when the patient is lying down.

Could lead to accidental loosening: Knots tied laterally may be more prone to accidental loosening, especially if the patient is restless or agitated.

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Correct Answer is D

Explanation

The correct answer is choice D. Reported history of alcoholism.

Choice A rationale:

Employment as a construction worker is not directly relevant to the administration of terbinafine HCL. While it may affect the client’s overall health and risk of injury, it does not impact the medication’s safety or efficacy.

Choice B rationale:

A white blood cell count of 8,500/mm³ (8.5 x 10³/L) is within the normal range and does not indicate any immediate concern that would affect the administration of terbinafine HCL.

Choice C rationale:

Thick and yellow toenails are typical symptoms of a fungal toenail infection and are the reason for prescribing terbinafine HCL. This finding confirms the diagnosis but does not present a contraindication to the medication.

Choice D rationale:

A reported history of alcoholism is crucial to address because terbinafine HCL can cause liver toxicity. Clients with a history of alcoholism are at higher risk for liver damage, and this must be carefully evaluated before starting the medication.

A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines. D. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.

Focusing on isolation at this point is a more effective way to prevent further transmission.

Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.

Choice B rationale:

Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:

COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.

Isolation physically separates the infected person from others, reducing the risk of transmission.

Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.

Choice D rationale:

Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.

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A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions.When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

Correct Answer is D

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

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A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions.
When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?