A client has a tracheostomy that is 3 days old. Upon assessment the nurse notes that the client's face is puffy and the eyelids are swollen. What action by the nurse takes best?

Correct Answer: A

Rationale: The correct answer is A: Assess the client's oxygen saturation. Puffy face and swollen eyelids could indicate a potential airway obstruction or compromised oxygenation. Assessing oxygen saturation will help determine if the client is adequately oxygenated. If oxygen saturation is low, immediate intervention may be needed. Choice B: Notifying the Rapid Response Team is premature without confirming the client's oxygen status first. Choice C: Oxygenating with a bag-valve-mask assumes the issue is solely related to oxygenation, which may not be the case. Choice D: Palpating the skin of the upper chest does not directly address the potential respiratory issue indicated by the client's presentation.

Correct Answer: A

Rationale: The correct answer is A. Tactile or vocal fremitus is assessed by placing the palms of the hands or the ulnar surface of the fingers on the chest wall while asking the patient to say 'ninety-nine' or '11'. This method allows the examiner to feel vibrations transmitted through the lung tissue. B is incorrect because repeating '11' is part of auscultation, not palpation. C refers to percussion, which is unrelated. D is incorrect as no vibrations are observed when the client remains quiet.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.