A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness.
Which action is most important for the nurse to instruct the client about self-care?

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.

Choice A rationale:

Incorrect. The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than carbon dioxide. They do not significantly convert carbon dioxide for elimination.

Elaboration: While the kidneys help regulate acid-base balance through reabsorption and excretion of bicarbonate and hydrogen ions, their role in carbon dioxide elimination is minimal. They primarily excrete acids like uric acid, phosphoric acid, and lactic acid.

Choice B rationale:

Incorrect. Hyperventilation would decrease carbon dioxide levels, not contribute to respiratory acidosis. Respiratory acidosis is characterized by elevated carbon dioxide levels.

Elaboration: Hyperventilation leads to rapid and excessive breathing, causing a decrease in carbon dioxide levels in the blood. This can result in respiratory alkalosis, not respiratory acidosis.

Choice C rationale:

Correct. Respiratory acidosis is caused by the accumulation of carbon dioxide in the blood. This can happen due to impaired ventilation, such as in conditions like chronic obstructive pulmonary disease (COPD), pneumonia, or respiratory failure.

Elaboration: Carbon dioxide is produced as a byproduct of cellular metabolism. It is normally removed from the body through exhalation. When ventilation is impaired, carbon dioxide cannot be efficiently eliminated, leading to its buildup in the blood. This excess carbon dioxide reacts with water to form carbonic acid, lowering blood pH and causing respiratory acidosis.

Choice D rationale:

Incorrect. Low blood oxygen levels (hypoxemia) can stimulate the respiratory rate, but this would not directly cause respiratory acidosis. It might lead to hyperventilation, which could potentially cause respiratory alkalosis.

Elaboration: The body's respiratory center in the brainstem regulates breathing based on blood oxygen and carbon dioxide levels. Hypoxemia triggers a compensatory increase in respiratory rate to enhance oxygen intake. However, this response does not directly contribute to respiratory acidosis.