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.

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Correct Answer is B

Explanation

"Most people are scared their first time in a health care facility":

While this statement normalizes the client's feelings by suggesting that many people feel scared initially, it might not directly address the client's specific concerns or provide the opportunity for a personalized discussion about their stay.

"We can discuss what you can expect during your stay":

This statement acknowledges the client's anxiety and opens the door for a conversation about the client's concerns. It provides an opportunity for the nurse to offer information, address specific worries, and offer support, fostering a sense of control for the client.

"You have nothing to worry about. Everything will be fine":

This statement, though well-intentioned, may come across as dismissive and overly optimistic. It might not validate the client's feelings or offer the opportunity for the client to express and discuss their concerns.

"Why are you feeling scared about being in this facility?":

While open-ended questions can help explore the client's feelings, in this context, it might be better to initially offer information and support before delving into the specific reasons for the client's anxiety. This allows the nurse to establish rapport and provide reassurance first.

A. I will walk three times per week." B. "I will take 250 milligrams of calcium once per day." C. I will decrease my intake of dairy products." D. I will avoid exposure to the sun.

Correct Answer is A

Explanation

A. "I will walk three times per week."

Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.

B. "I will take 250 milligrams of calcium once per day."

This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.

C. "I will decrease my intake of dairy products."

Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.

D. "I will avoid exposure to the sun."

Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.

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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

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Correct Answer is A

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