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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 C

Explanation

Choice A rationale

Lansoprazole, a proton pump inhibitor (PPI), typically requires several weeks to achieve its full therapeutic effect. Notifying the healthcare provider for a dosage change after only one week is premature and not supported by clinical guidelines.

Choice B rationale

Auscultating bowel sounds and measuring abdominal girth are not directly related to the effectiveness of lansoprazole in treating GERD. These actions are more relevant for assessing gastrointestinal motility and potential complications like bowel obstruction.

Choice C rationale

Healing of erosive esophagitis with PPIs like lansoprazole usually takes several weeks. Advising the client that healing typically takes several weeks to occur is appropriate and aligns with the expected therapeutic timeline.

Choice D rationale

Lansoprazole should be taken before meals, not after, to maximize its effectiveness. Confirming that the client is taking the medication one hour after meals would not address the issue of symptom persistence.

Correct Answer is B

Explanation

Choice A rationale

Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.

Choice B rationale

Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.

Choice C rationale

Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.

Choice D rationale

Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.

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