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.

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Correct Answer is A

Explanation

Choice A reason: Furosemide, a loop diuretic, promotes urine output by inhibiting sodium reabsorption in the kidneys, reducing fluid overload in heart failure. Increased urine output indicates effective diuresis, alleviating pulmonary and peripheral edema, making it the primary sign of therapeutic efficacy.

Choice B reason: Elevated blood pressure is not an expected effect of furosemide, which reduces preload and blood volume, often lowering pressure. Effective diuresis is shown by increased urine output, as this directly reflects fluid removal, critical for heart failure management.

Choice C reason: Increased heart rate is not a direct indicator of furosemide efficacy. Diuresis reduces cardiac workload, potentially stabilizing heart rate, but urine output is the primary measure, as it confirms fluid excretion, the medication’s main action in heart failure.

Choice D reason: Weight gain indicates fluid retention, the opposite of furosemide’s goal. Effective diuresis causes weight loss due to fluid excretion. Increased urine output is the key sign, as it directly measures the diuretic’s action in reducing heart failure-related fluid overload.

A. Obtain arterial blood gases B. Suction to clear secretions from airway C. Offer a prescribed PRN analgesia D. Administer a prescribed antipyretic

Correct Answer is B

Explanation

Choice A reason: Arterial blood gases assess oxygenation and acid-base balance, critical for diagnosing respiratory distress severity. However, this diagnostic measure does not immediately relieve airway obstruction. Clearing secretions is prioritized to restore ventilation, as hypoxia can rapidly cause tissue damage or cardiac arrest in acute respiratory distress.

Choice B reason: Suctioning removes airway secretions, directly addressing breathing difficulty. Secretions obstruct airways, reducing oxygen delivery to alveoli and impairing gas exchange. Immediate suctioning restores patency, enhances ventilation, and prevents hypoxia, making it the priority intervention to stabilize the client’s respiratory function in acute distress.

Choice C reason: PRN analgesia addresses pain, which is not indicated as the primary issue. Pain relief does not resolve airway obstruction or improve breathing. Administering analgesia prematurely could mask respiratory symptoms, delaying critical airway management and potentially worsening hypoxia by neglecting the underlying obstruction.

Choice D reason: An antipyretic reduces fever, improving comfort but not addressing breathing difficulty. Fever is secondary, and treating it does not restore airway patency or oxygenation. Airway management is prioritized in respiratory distress to prevent hypoxia and ensure effective gas exchange before managing fever symptoms.

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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

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