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A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

A.

Secure tracheostomy ties by making knots close to the tube.

B.

Remove ties to secure a disposable, soft foam collar with hook and loop fastener.

C.

Leave the old ties in place until the new ones are secure.

D.

Place knots of the ties laterally to prevent irritation and pressure.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Securing tracheostomy ties by making knots close to the tube can cause irritation and pressure on the skin.

 

Choice B rationale

 

Removing ties to secure a disposable, soft foam collar with hook and loop fastener is not the most important action when changing the ties of the tracheostomy tube.

 

Choice C rationale

 

Leaving the old ties in place until the new ones are secure is the most important action to prevent accidental dislodgement of the tracheostomy tube.

 

Choice D rationale

 

Placing knots of the ties laterally to prevent irritation and pressure is important but not the most critical action when changing the ties of the tracheostomy tube.


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Correct Answer is A

Explanation

Choice A rationale

pH 7.49, PCO₂ 45 mm Hg, HCO₃ 32 mEq/L (32 mmol/L), PO₂ 90 mm Hg indicates metabolic alkalosis. The elevated pH and HCO₃ levels are consistent with this condition.

Choice B rationale

pH 7.30, PCO₂ 20 mm Hg, HCO₃ 22 mEq/L (22 mmol/L), PO₂ 85 mm Hg indicates metabolic acidosis with respiratory compensation, not metabolic alkalosis.

Choice C rationale

pH 7.46, PCO₂ 55 mm Hg, HCO₃ 36 mEq/L (36 mmol/L), PO₂ 95 mm Hg indicates metabolic alkalosis with respiratory compensation. However, the pH is slightly lower than in Choice A, making Choice A more indicative of metabolic alkalosis.

Choice D rationale

pH 7.29, PCO₂ 35 mm Hg, HCO₃ 25 mEq/L (25 mmol/L), PO₂ 99 mm Hg indicates metabolic acidosis, not metabolic alkalosis.

Correct Answer is C

Explanation

Choice A rationale

Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.

Choice B rationale

Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.

Choice C rationale

Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.

Choice D rationale

Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.

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