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 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
Topical antifungals are used to treat fungal infections and are not effective for psoriasis, which is an autoimmune condition.
Choice B rationale
Colloidal oatmeal-based lotion can help soothe the skin but does not address the underlying inflammation and scaling associated with psoriasis.
Choice C rationale
Topical corticosteroids are the mainstay of treatment for psoriasis. They help reduce inflammation, itching, and redness associated with psoriatic plaques.
Choice D rationale
Topical analgesics can help relieve pain but do not address the underlying inflammation and scaling associated with psoriasis.