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 A

Explanation

A. "It's nice having other people cook for me.":

This statement suggests adaptation to the new situational role. The client expresses a positive view of receiving help and support in daily activities, indicating a level of acceptance and adjustment to the changed living situation.

B. "I've never been the kind of person to ask others for help.":

This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.

C. "I'm looking forward to being able to be independent again.":

This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.

D. "I really don't know what I'm supposed to do all day.":

This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.

A. Whisper a series of words softly into one ear. B. Place an activated tuning fork in the middle of the client's forehead. C. Deliver a series of high-pitched sounds at random intervals. D. Hold an activated tuning fork against the client's mastoid process.

Correct Answer is B

Explanation

A. Whisper a series of words softly into one ear.

Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.

B. Place an activated tuning fork in the middle of the client's forehead.

Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.

C. Deliver a series of high-pitched sounds at random intervals.

Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.

D. Hold an activated tuning fork against the client's mastoid process.

Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.

Solved] In Weber's test, lateralization of sound to diseased ear

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