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 C
Explanation
Rationale for Choice A:
Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.
Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.
Rationale for Choice B:
Reports of chronic constipation are not typically associated with acute pancreatitis.
Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.
Rationale for Choice C:
Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.
Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.
Rationale for Choice D:
Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.
Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.
Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.
Correct Answer is ["B","C"]
Explanation
Choice B rationale:
Gravity Facilitates Drainage:
Positioning the patient strategically utilizes gravity to encourage the flow of fluids and secretions away from the surgical site. This aids in preventing fluid accumulation and potential infection.
Reduces Pressure on Surgical Site:
Certain positions can minimize pressure on the incision and internal organs, promoting healing and reducing discomfort.
This is particularly important for patients with comorbidities like hypertension and heart failure, as they may have impaired wound healing and be more susceptible to respiratory complications.
Enhances Respiratory Function:
Specific positions can improve lung expansion and ventilation, which is essential for patients with a history of heart failure or respiratory issues.
This helps prevent atelectasis (collapsed lung areas) and pneumonia, which are common postoperative risks.
Common Post-Cholecystectomy Positions:
Semi-Fowler's Position:
The head of the bed is elevated 30-45 degrees, with knees slightly bent.
This position eases breathing, reduces pressure on the incision, and promotes drainage of fluids. Right Side-Lying Position:
The patient lies on their right side with a pillow between their knees.
This position encourages drainage from the liver and gallbladder, aiding in bile flow. Left Side-Lying Position:
The patient lies on their left side with a pillow between their knees.
This position promotes drainage from the stomach and pancreas, assisting in digestion. Supine Position:
The patient lies flat on their back with a pillow under their knees.
This position may be used for short periods, but prolonged supine positioning can increase pressure on the incision and lungs. High Fowler's Position:
The head of the bed is elevated 60-90 degrees, with knees slightly bent.
This position is often used for patients with respiratory issues or difficulty breathing, as it improves lung expansion.
Choice C rationale:
Performing drainage immediately after meals aids in efficient removal of bile and gastric secretions, preventing complications such as:
Bile Reflux:
Delayed drainage can cause bile to back up into the stomach, leading to nausea, vomiting, and discomfort. Infection:
Accumulation of fluids in the surgical site can increase the risk of bacterial growth and infection. Pancreatitis:
In rare cases, delayed drainage can cause inflammation of the pancreas due to obstruction of the pancreatic duct.
I'll address the rationales for choices A and D in the following sections.
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