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 C
Explanation
Choice A rationale
Restricting fluids is not a primary limitation for clients with Crohn’s disease. Adequate hydration is important for overall health and managing symptoms.
Choice B rationale
Limiting foods high in calcium and iron is not typically recommended for Crohn’s disease. These nutrients are important for maintaining bone health and preventing anemia, which can be concerns for individuals with Crohn’s disease.
Choice C rationale
An elimination diet can help identify trigger foods that may exacerbate symptoms of Crohn’s disease. This approach involves removing certain foods from the diet and gradually reintroducing them to determine which foods cause symptoms.
Choice D rationale
Avoiding gluten is not necessary for all individuals with Crohn’s disease. While some may benefit from a gluten-free diet, it is not a universal recommendation for managing the condition.
Correct Answer is B
Explanation
Choice A rationale
Ipratropium is a bronchodilator used to treat respiratory conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.
Choice B rationale
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding and ulcers, especially when combined with other medications that affect the stomach lining, such as bismuth subsalicylate and tetracycline. Reviewing the client’s use of aspirin is important to prevent potential adverse effects and complications.
Choice C rationale
Famotidine is an H2 receptor antagonist used to reduce stomach acid production. While it is relevant to gastrointestinal health, it does not have significant interactions with the H. pylori treatment regimen. Therefore, it is not a priority to review in this context.
Choice D rationale
Loperamide is an antidiarrheal medication used to manage diarrhea. It does not have significant interactions with the medications prescribed for H. pylori treatment, so it is not a priority to review in this context.