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

A. Yogurt with fruit:

While yogurt with fruit is a soft and easily digestible option, it is not representative of a progression from a clear liquid diet to a full liquid diet. Yogurt is typically included in a full liquid diet, but the addition of fruit may introduce solid particles. The transition from clear to full liquids usually involves avoiding solid or textured foods.

B. Pudding:

Pudding is a suitable choice that aligns with the progression from a clear liquid diet to a full liquid diet. Pudding is a smooth and creamy food, making it appropriate for someone transitioning from clear liquids. It provides a source of calories and is easy to swallow, meeting the criteria for a full liquid diet.

C. Cooked vegetables:

Cooked vegetables are not part of a full liquid diet. While they are a healthy food choice, they are too textured for someone transitioning from a clear liquid diet. Full liquid diets focus on foods that are liquid at room temperature or become liquid when they reach body temperature.

D. Bananas:

Bananas are a soft and easily digestible fruit, but they are not typically included in a full liquid diet. The texture of bananas may be too thick for someone progressing from a clear liquid diet, and they are not considered a liquid or a food that becomes liquid at room temperature.

A. The hot water heater is set to 47° C (117° F). B. Grab bars are installed in the shower. C. There is an area rug covering a tile floor. D. Prescriptions are stored in a medication organizer.

Correct Answer is C

Explanation

A. The hot water heater is set to 47° C (117° F).This temperature is within a safe range to prevent burns while ensuring adequate hot water for hygiene.

B. Grab bars are installed in the shower.Grab bars provide support and help prevent falls in older adults, especially those with osteoporosis who are at higher risk for fractures.

C. There is an area rug covering a tile floor.Area rugs are a significant tripping hazard, especially for older adults with osteoporosis, as a fall could lead to fractures. The nurse should intervene to recommend removing or securing the rug to reduce the risk of falls.

D. Prescriptions are stored in a medication organizer.A medication organizer helps older adults manage their medications effectively and reduces the risk of missed or incorrect doses.

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A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

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