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
Trouble sleeping is not directly relevant to the administration of pyridostigmine, which is used to improve muscle strength in myasthenia gravis.
Choice B rationale
Unexplained weight loss is not a primary concern when administering pyridostigmine. The focus should be on the patient’s ability to swallow and recent oral intake.
Choice C rationale
Difficulty with urination is not a primary concern for pyridostigmine administration. The medication’s effects on muscle strength and swallowing are more critical.
Choice D rationale
Recent oral intake is crucial to assess because pyridostigmine can cause gastrointestinal side effects, and food intake can affect its absorption and effectiveness.
Correct Answer is D
Explanation
Choice A rationale
Counting the apical and radial pulses simultaneously is important for assessing pulse deficits, but it is not the most critical assessment for a client receiving hydromorphone.
Choice B rationale
Measuring the client’s capillary glucose level is important for clients with diabetes, but it is not directly related to the administration of hydromorphone.
Choice C rationale
Observing for edema around the ankles is important for assessing fluid retention, but it is not the most critical assessment for a client receiving hydromorphone.
Choice D rationale
Auscultating the client’s bowel sounds is crucial because hydromorphone is a potent opioid analgesic that can slow peristalsis and frequently causes constipation. Monitoring bowel sounds helps prevent complications such as bowel obstruction. .