A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Use a quick-release knot to secure the ties.

Cut the old ties after the new ties are secured.

Allow space for three fingers under the ties when securing.

Extend the client's neck while securing the ties

Answer and Explanation

The Correct Answer is B

Correct answer: B

A. Use a quick-release knot to secure the ties:

This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.

B. Cut the old ties after the new ties are secured:

This is the safest approach. It ensures the tracheostomy tube remains secure throughout the change.

C. Allow space for three fingers under the ties when securing:

Two fingers is the recommended space to allow for breathing comfort and prevent the tube from being too loose..

D. Extend the client's neck while securing the ties:

This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.

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 C

Explanation

A. Occupational therapist:

While occupational therapists play a valuable role in stroke rehabilitation, they typically focus on activities of daily living (ADLs), upper extremity function, and adaptive strategies. In the context of frequent coughing during swallowing, the expertise of an SLP is more directly relevant to address potential dysphagia.

B. Physical therapist:

Physical therapists primarily focus on mobility, strength, and balance. While they may be involved in stroke rehabilitation, the issue of coughing during swallowing is more aligned with the scope of practice of a speech-language pathologist.

C. Speech-language pathologist:

This is the correct answer. A speech-language pathologist (SLP) specializes in assessing and treating communication and swallowing disorders. In this case, the client is experiencing coughing when swallowing, indicating a potential swallowing (dysphagia) issue. The SLP can conduct a thorough evaluation of the client's swallowing function and recommend appropriate interventions, such as swallowing exercises or modified diets, to address the coughing and improve safe swallowing.

D. Social worker:

Social workers provide support for psychosocial and community-related issues. While they are crucial members of the interdisciplinary team, they may not have the specific expertise needed to address the swallowing difficulties experienced by the client after a stroke

A. A feeling of swelling in the feet B. Pain at the injection site C. A sudden decrease in heart rate D. A sharp decrease in blood pressure

Correct Answer is D

Explanation

A. A feeling of swelling in the feet:

Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.

B. Pain at the injection site:

Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.

C. A sudden decrease in heart rate:

An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.

D. A sharp decrease in blood pressure:

This is the correct answer. Anaphylactic reactions can lead to a sudden and severe drop in blood pressure, which is a critical and life-threatening symptom. This is due to the release of vasodilatory substances and increased permeability of blood vessels, resulting in a decrease in blood volume within the vessels.

Anaphylactic Shock: A life-threatening reaction | Henrylito D. Tacio

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 nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke and coughs frequently when swallowing. The nurse should request a referral to which of the following members of the interdisciplinary team?

Correct Answer is C

Explanation

A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?

Correct Answer is D

Explanation

A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?

A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

A nurse manager overhears a nurse telling a client. "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?