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?
Secure tracheostomy ties by making knots close to the tube.
Remove ties to secure a disposable, soft foam collar with hook and loop fastener.
Leave the old ties in place until the new ones are secure.
Place knots of the ties laterally to prevent irritation and pressure.
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 D
Explanation
Choice A rationale
Observing pupil response of the right eye is not relevant to the care of the left eye post-cataract extraction.
Choice B rationale
Sleeping flat in a supine position is not recommended as it can increase intraocular pressure. Elevating the head is advised.
Choice C rationale
Turning, coughing, and deep breathing every 2 hours is not specific to cataract surgery and can increase intraocular pressure.
Choice D rationale
Administering a stool softener is important to prevent straining during bowel movements, which can increase intraocular pressure and affect healing.
Correct Answer is C
Explanation
Choice A rationale
Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.
Choice B rationale
Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.
Choice C rationale
Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.
Choice D rationale
Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.