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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Chest x-ray may show nonspecific findings in pulmonary embolism but is not diagnostic. D-dimer, a fibrin degradation product, is highly sensitive for detecting thrombosis, guiding further imaging like CT pulmonary angiography, making it the priority test in suspected cases.

Choice B reason: Electrocardiogram may show tachycardia or right heart strain in pulmonary embolism but is nonspecific. D-dimer is a sensitive screening test, indicating clot presence, which prompts definitive imaging, making it the preferred initial diagnostic step in suspected pulmonary embolism.

Choice C reason: D-dimer blood test is the most sensitive screening tool for pulmonary embolism, detecting fibrin degradation from clots. Elevated levels prompt CT pulmonary angiography for confirmation, guiding urgent treatment to prevent further embolization, making it the critical test to anticipate.

Choice D reason: Arterial blood gas may reveal hypoxemia in pulmonary embolism but is nonspecific, as other conditions cause similar findings. D-dimer is more diagnostic, identifying clot presence, guiding imaging, and ensuring timely intervention, making it the priority test in suspected cases.

A. Obtain an arterial blood gas prior to the procedure B. Perform the drainage immediately after meals C. Instruct the client to breathe shallow and fast D. Explain that the client may be placed in five positions

Correct Answer is D

Explanation

Choice A reason: Obtaining an arterial blood gas assesses oxygenation and acid-base status, useful in COPD management, but is not required before postural drainage. This invasive procedure is unnecessary for routine drainage, which mobilizes secretions. Explaining positions prepares the client, enhancing cooperation and effectiveness.

Choice B reason: Performing drainage after meals risks aspiration or vomiting, as a full stomach increases intra-abdominal pressure in COPD patients. Postural drainage is most effective when performed on an empty stomach, making this approach incorrect. Patient education on positioning is the priority.

Choice C reason: Shallow, fast breathing is counterproductive in COPD, as it reduces tidal volume and worsens hypercapnia. Postural drainage requires slow, deep breaths to mobilize secretions and improve ventilation. Explaining positions ensures proper technique, making this breathing instruction incorrect.

Choice D reason: Explaining that the client may be placed in five positions (e.g., prone, supine, lateral) prepares them for postural drainage, which uses gravity to mobilize lung secretions in COPD. This education enhances compliance and effectiveness, as proper positioning is critical for therapeutic success, making it the correct approach.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic test should the nurse anticipate?

Correct Answer is C

Explanation

When performing postural drainage on a client with chronic obstructive pulmonary disease, which approach should the nurse use?

Correct Answer is D

Explanation

The nurse is caring for a client with a new diagnosis of epilepsy who is prescribed phenytoin. Which teaching point should the nurse emphasize?

The nurse is caring for a client with a history of multiple sclerosis. Which intervention should the nurse prioritize?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction should the nurse emphasize?

The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which assessment should the nurse prioritize?

The nurse is caring for a client with a history of hypertension. Which lifestyle modification should the nurse emphasize?

The nurse is caring for a client with a history of gout. Which dietary recommendation should the nurse emphasize?

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?