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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Drinking plenty of water whenever thirsty is not the most appropriate action for a patient with hypernatremia. While it's important to stay hydrated, excessive water intake can potentially worsen hypernatremia by diluting blood sodium levels further. This is because the body tries to balance sodium levels by either retaining water or excreting it through urine. In hypernatremia, the body is already short on water relative to sodium, so consuming too much water can exacerbate the imbalance.
Choice B rationale:
Reviewing food labels for sodium content is crucial for managing hypernatremia. It empowers patients to make informed choices and limit their sodium intake.
Sodium is a major contributor to hypernatremia, and reducing dietary sodium intake is a key strategy to lower blood sodium levels.
By carefully reading food labels and selecting low-sodium options, patients can effectively manage their sodium intake and promote a gradual return to normal sodium levels.
This approach addresses the root cause of hypernatremia and promotes long-term control of blood sodium levels.
Choice C rationale:
Monitoring daily urine output volume can be helpful in tracking fluid status, but it's not the primary action for managing hypernatremia.
While urine output can provide insights into fluid balance, it doesn't directly address the underlying issue of excessive sodium. Focusing on dietary sodium intake is a more direct and effective approach to correcting hypernatremia.
Choice D rationale:
Using salt tablets after strenuous exercise is not recommended for patients with hypernatremia.
Salt tablets are intended to replenish electrolytes lost through sweating, but they can worsen hypernatremia by further increasing sodium levels.
Patients with hypernatremia should focus on reducing sodium intake, not increasing it.
Correct Answer is B
Explanation
A Colloidal oatmeal-based lotion: Colloidal oatmeal can help to reduce itching and swelling, all while hydrating the skin. It is often used to soothe irritated skin and can be incorporated into a skincare routine through oatmeal baths or oatmeal-infused moisturizers. However, it is typically used as a complementary treatment and may not be sufficient to manage psoriasis symptoms on its own.
B Topical corticosteroids: These are an essential tool for treating inflammatory skin conditions such as psoriasis34. They work by reducing inflammation and slowing down the production of skin cells, which helps to alleviate symptoms such as redness, itching, and scaling. Topical corticosteroids are often the first line of treatment for mild to moderate psoriasis.
C. Topical analgesics: These are primarily used to relieve pain. While they may provide some relief from discomfort associated with psoriasis, they do not address the underlying inflammation and rapid skin cell production that characterize this condition.
D Topical antifungal: Antifungal agents are typically used to treat conditions like seborrheic dermatitis and scalp psoriasis, or in areas where psoriasis involves folds in the skin, where there is an increased potential for localized infection. However, they are not typically used as a primary treatment for psoriasis.
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