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: B

Rationale: The correct answer is B: Notify the Rapid Response Team. Puffy face and swollen eyelids can indicate a potential airway obstruction, which is a medical emergency. Notifying the Rapid Response Team ensures prompt intervention and appropriate management. Assessing oxygen saturation (A) may be important but addressing the potential obstruction takes priority. Oxygenating with a bag-valve-mask (C) may worsen the obstruction. Palpating the skin of the upper chest (D) is not directly related to addressing the potential airway issue.

Correct Answer: B

Rationale: The correct answer is B because chest pain lasting longer than 30 minutes is a common characteristic of an acute myocardial infarction (heart attack). This prolonged duration indicates cardiac tissue damage. Choices A, C, and D are incorrect. Choice A, pain increasing with deep breathing, is more indicative of musculoskeletal pain. Choice C, pain relieved by nitroglycerin, is suggestive of angina rather than a heart attack. Choice D, reproducible pain with arm movement, is more consistent with musculoskeletal or nerve-related pain rather than a heart attack.

Correct Answer: C

Rationale: Step 1: Jugular venous distention (JD) indicates increased pressure in the right atrium. Step 2: When the head of the bed is elevated, gravity helps blood return to the right side of the heart. Step 3: If JD is present with head elevation, it suggests that the right atrial pressure is elevated. Step 4: Elevated right atrial pressure often indicates heart failure or fluid overload. Step 5: Therefore, the correct answer is C: Increased right atrial pressure. Summary: A: Decreased fluid volume is incorrect because JD suggests fluid overload, not decreased volume. B: Jugular vein atherosclerosis is incorrect as JD is not typically associated with atherosclerosis. D: Incompetent jugular vein valves is incorrect as JD is more likely due to increased pressure than valve incompetence.

Correct Answer: A

Rationale: Step 1: Assess for anxiety - The client's lack of comprehension, forgetfulness, and repetitive questions indicate potential anxiety affecting their ability to process information. Step 2: Identify potential anxiety cues - Look for signs such as restlessness, increased heart rate, or verbal expressions of worry. Step 3: Address anxiety first - Once anxiety is identified, the nurse can provide appropriate interventions to help the client better understand and retain the information. Step 4: Provide supportive measures - After addressing anxiety, breaking information into smaller bits, giving written information, and reviewing the information can be helpful, but addressing anxiety is key to enhancing the client's ability to comprehend and retain information.

Correct Answer: C

Rationale: The correct answer is C: Need for frequent laboratory blood testing. For a patient on warfarin with a mechanical valve, regular monitoring of the international normalized ratio (INR) is essential to ensure the medication's effectiveness and prevent complications like clotting or bleeding. Incorrect choices: A - Aspirin is not recommended with warfarin due to increased bleeding risk. B - Knowing how to take radial pulse is not directly related to warfarin therapy. D - Avoiding physical activity is not necessary; instead, patients should engage in regular, moderate exercise unless advised otherwise by a healthcare provider.