Question

The nurse is changing a client’s tracheostomy tie. What method is used to assure that the tie is not too tightly placed? The

a)the leaves no marks on the neck area

b) tracheotomy tube can be pulled slightly away from the neck

c) nurse can place one or two fingers between the tie and neck

d) nurse uses a 12 inch tie that is snugly affixes around the neck

2) a nurse is monitoring the APTT for a client receiving heparin therapy. The nurse should perform which action when the latest reported APTT is 2.0 times the control?

a)report the wnl value during the inter shift report

b) assess the client for an increase in abnormal bleeding

c) be prepared to increase the heparin subcutaneous dosage

d) notify the physician of the elevated APTT level

Answer 1

1 . The answer is ------ c . Nurse can place one or two fingers between the tie and the neck.

Explanation : To ensure that the tracheostomy is not too tight which can cause complications can be prevented by placing one or two fingers in between the tie and the neck.

2 . The answer is ------ b ) Assess the client for an increase in abnormal bleeding.

Explanation :

Activated Partial Thromboplastin time is a measure of intrinsic pathway of clotting mechanism. Elevated levels indicate it is taking time for the blood to clot and there is increased chance of bleeding and therefore the first measure is to check if there is any bleeding due to extended APTT time.

Thank you.