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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Auscultating bowel sounds and measuring abdominal girth are not directly related to the management of erosive esophagitis and GERD symptoms. These actions are more pertinent to assessing gastrointestinal motility and distension, not the effectiveness of lansoprazole.

Choice B rationale: Lansoprazole is a proton pump inhibitor that should be taken before meals to reduce stomach acid production effectively. Confirming that the patient is taking the medication before meals could help optimize its efficacy but is not the most immediate step.

Choice C rationale: Notifying the healthcare provider about a potential need for a dosage change may be considered if symptoms persist. However, since healing with proton pump inhibitors can take several weeks, this action may be premature after only one week of use.

Choice D rationale: It is appropriate to inform the patient that healing of erosive esophagitis and symptom relief from GERD can take several weeks with lansoprazole. This education helps set realistic expectations and encourages adherence to the prescribed treatment.

A. Explain to the client that antibiotics are not useful in treating viral infections such as influenza. B. Advise the client that once symptoms occur it is too late to receive an influenza vaccination. C. Refer the client to the healthcare provider at the clinic to obtain a medication prescription. D. Instruct the client that over-the-counter medications are sufficient to manage influenza symptoms.

Correct Answer is C

Explanation

Choice A rationale:

It is true that antibiotics are not effective against viruses like influenza. They only work against bacteria.

However, while providing this information to the client is accurate, it does not directly address the client's inquiry about taking oseltamivir, which is an antiviral medication.

It's essential for the nurse to guide the client toward the appropriate healthcare provider who can assess the client's condition and make an informed decision about whether oseltamivir is a suitable treatment option.

Choice B rationale:

While it is true that influenza vaccination is most effective when given before exposure to the virus, it is still a relevant consideration even after symptoms have begun.

Studies have shown that antiviral medications like oseltamivir can potentially reduce the severity and duration of influenza symptoms, even when started within 48 hours of symptom onset.

Therefore, simply advising the client that it's too late for vaccination without exploring other potential treatment options would be incomplete and potentially disadvantageous to the client's care.

Choice C rationale:

This is the most appropriate response because it ensures that the client receives a comprehensive assessment and individualized treatment plan from a qualified healthcare provider.

The provider can evaluate the client's symptoms, medical history, and potential risk factors to determine if oseltamivir is a suitable medication.

Additionally, the provider can discuss other potential treatment options, such as over-the-counter medications for symptom relief, and provide guidance on self-care measures to promote recovery.

Choice D rationale:

While over-the-counter medications can help manage some symptoms of influenza, such as fever, aches, and cough, they do not directly target the virus itself.

Antiviral medications like oseltamivir can potentially shorten the duration of the illness and reduce the risk of complications, especially in individuals at higher risk.

Therefore, relying solely on over-the-counter medications without considering antiviral therapy could potentially delay recovery and increase the likelihood of adverse outcomes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Correct Answer is D

Explanation

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection.Which response should the nurse provide?

Correct Answer is C

Explanation

A client with emphysema reports difficulty breathing and exhibits audible wheezing.The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 ml of D5W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer.The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

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?

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection.Prior to administering theH. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

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?