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
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.
Correct Answer is A
Explanation
Choice A rationale:
Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy.
Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance.
Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers.
Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.
Choice B rationale:
Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma.
Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy.
Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.
Choice C rationale:
Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection.
Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections.
Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.
Choice D rationale:
Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections.
Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general.
Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.
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