The nurse is securing a tracheostomy tube for a client post-procedure. Which action should the nurse take to ensure proper tracheostomy care?

Remove ties to secure a disposable, soft foam collar with hook and loop fastener

Secure tracheostomy ties by making knots close to the tube

Leave the old ties in place until the new ones are secure

Place knots of the ties lateral to prevent irritation and pressure

Answer and Explanation

The Correct Answer is C

Choice A reason: Using a soft foam collar may reduce skin irritation but risks dislodging the tracheostomy tube if not secured properly. Leaving old ties in place until new ones are secure ensures tube stability, preventing accidental decannulation, which is critical in early tracheostomy care.

Choice B reason: Knots close to the tracheostomy tube increase pressure on the skin, risking irritation or necrosis. This is incorrect, as ties should allow slight movement. Maintaining old ties until new ones are secure prevents tube displacement, prioritizing airway safety during the procedure.

Choice C reason: Leaving old ties in place until new ones are secure prevents tracheostomy tube dislodgement, a life-threatening risk. This ensures continuous airway patency during tie changes, especially in fresh tracheostomies, making it the safest and most critical action to maintain tube stability.

Choice D reason: Placing knots laterally reduces irritation but does not address the risk of tube dislodgement during tie changes. Keeping old ties in place until new ones are secure is the priority, as it ensures the tube remains stable, preventing airway compromise.

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Correct Answer is A

Explanation

Choice A reason: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.

Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.

Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.

Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.

A. Maintain consistent salt intake B. Avoid high-fiber foods C. Increase caffeine consumption D. Limit physical exercise

Correct Answer is A

Explanation

Choice A reason: Consistent salt intake is critical for lithium, as sodium levels affect lithium excretion. Low sodium increases lithium toxicity, causing tremors or confusion. Maintaining stable sodium intake ensures therapeutic levels, making this the priority teaching point for safe lithium therapy.

Choice B reason: Avoiding high-fiber foods is irrelevant to lithium therapy. Fiber affects gastrointestinal health but not lithium pharmacokinetics. Consistent salt intake is essential, as sodium fluctuations alter lithium clearance, risking toxicity, making dietary sodium the priority teaching focus.

Choice C reason: Increasing caffeine is inappropriate, as it may exacerbate bipolar symptoms and increase lithium excretion, risking subtherapeutic levels. Consistent salt intake stabilizes lithium levels, preventing toxicity or inefficacy, making it the critical teaching point for effective bipolar management.

Choice D reason: Limiting physical exercise is unnecessary for lithium therapy. Exercise supports mental health in bipolar disorder but does not directly affect lithium levels. Consistent salt intake is the priority, as sodium balance ensures safe and effective lithium therapy.

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The nurse is securing a tracheostomy tube for a client post-procedure. Which action should the nurse take to ensure proper tracheostomy care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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