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

Correct Answer: A

Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.

Correct Answer: A

Rationale: The correct answer is A: Assess the client's lung sounds. This action takes priority because the client experienced a coughing spell, indicating a potential aspiration risk. Assessing lung sounds can help determine if there is any respiratory distress or compromised airway. B: Assigning a different UAP does not address the immediate concern of the client's respiratory status. C: Reporting the UAP to the manager may be necessary but is not the immediate priority when the client's health is at risk. D: Requesting thicker liquids for meals does not address the client's current condition and may not be appropriate without proper assessment.

Correct Answer: C

Rationale: The correct answer is C: Tying a square knot at the back of the neck. The reason this action requires intervention is that a square knot is not recommended for securing tracheostomy ties as it can be difficult to untie in an emergency. Instead, a quick-release knot or Velcro closure is typically used for easy removal. A: Holding the device securely when changing ties is important for maintaining the integrity of the tracheostomy. B: Suctioning the client first if secretions are present is a standard practice to ensure clear airways. D: Using half-strength peroxide for cleansing is appropriate for tracheostomy care to prevent infection. In summary, the incorrect choice is C because tying a square knot can pose risks in an emergency situation, while the other choices are appropriate actions in tracheostomy care.

Correct Answer: A

Rationale: The correct answer is A. When suctioning a tracheostomy, the student should not apply suction while withdrawing the catheter to prevent mucosal damage. The correct technique involves inserting the catheter without applying suction, then withdrawing it while applying suction. This helps to clear secretions effectively without causing trauma. Choices B, C, and D are incorrect. Preoxygenating the client is a recommended practice to prevent hypoxemia during suctioning. Suctioning up to three times if necessary and suctioning for 10-15 seconds each time are appropriate techniques to clear secretions effectively without causing harm.

Correct Answer: B

Rationale: The correct answer is B because intact skin behind the ears indicates proper oxygen delivery, ensuring the client's respiratory needs are being met. This assessment finding shows that the oxygen therapy is effective in improving oxygenation. A: This choice is incorrect as the client's meal intake does not directly reflect the effectiveness of oxygen therapy. C: Although important, the client's understanding of the need for oxygen does not directly indicate the success of the oxygen therapy. D: Unchanged weight is not a direct indicator of the effectiveness of oxygen therapy in this situation.