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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Anorexia is common in hepatitis due to systemic inflammation but is nonspecific, occurring in many conditions. Clay-colored stools directly indicate impaired bile excretion from liver dysfunction, a hallmark of hepatitis, making it a more diagnostic finding.
Choice B reason: Clay-colored stools are highly indicative of hepatitis, as liver inflammation impairs bile production or excretion, reducing bilirubin in feces. This causes pale stools, reflecting hepatic dysfunction, making it a key finding to confirm hepatitis over nonspecific symptoms like anorexia.
Choice C reason: Brown, foamy urine is not typical of hepatitis. Dark urine from bilirubinuria may occur, but foamy urine suggests proteinuria, unrelated to liver dysfunction. Clay-colored stools are more specific, indicating bile flow obstruction, a direct sign of hepatitis pathology.
Choice D reason: Hematemesis indicates gastrointestinal bleeding, not a primary hepatitis feature. While advanced liver disease may cause variceal bleeding, clay-colored stools are an earlier, more specific sign of hepatitis-related bile impairment, making them the priority finding in acute cases.
Correct Answer is B
Explanation
Choice A reason: Serum creatinine assesses kidney function, not cardiac injury. While relevant for overall health, it does not confirm myocardial infarction. Troponin is specific to cardiac muscle damage, making it the priority test to diagnose acute coronary events in the emergency setting.
Choice B reason: Troponin levels are the gold standard for diagnosing myocardial infarction, as they rise within hours of cardiac muscle injury due to ischemia. High specificity for heart tissue makes troponin critical for confirming acute coronary syndrome, guiding urgent treatment in the emergency department.
Choice C reason: Complete blood count evaluates anemia or infection but is nonspecific for myocardial infarction. While useful for overall assessment, it does not detect cardiac injury. Troponin directly indicates heart muscle damage, making it the priority test for confirming the diagnosis.
Choice D reason: Blood glucose may be elevated in stress or diabetes but is not diagnostic for myocardial infarction. Cardiac-specific markers like troponin are essential for confirming heart injury, as glucose levels lack specificity for acute coronary events, making them secondary.
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