A client has a tracheostomy tube in place. When the nurse suctions the client food particles are noted. What action by the nurse is best?

Correct Answer: B

Rationale: The correct answer is B: Measure and compare cuff pressures. When food particles are noted during suctioning, it indicates a potential issue with the tracheostomy tube cuff. By measuring and comparing cuff pressures, the nurse can ensure the cuff is properly inflated to prevent aspiration of food particles into the lungs. Elevating the head of the bed (choice A) is a standard practice for preventing aspiration but does not address the specific issue of cuff pressure. Placing the client on NPO status (choice C) is not necessary if the cuff pressure is the main concern. Requesting a swallow study (choice D) may be needed eventually but is not the immediate priority when food particles are already present.

Correct Answer: A

Rationale: The correct answer is A. For thoracentesis, the client typically sits at the edge of the bed, leaning forward with arms supported on a table or over their knees to spread out the intercostal spaces and stabilize the chest wall. B is incorrect because lying on the affected side would compress the area being accessed. C is wrong as lying flat reduces access to the pleural space. D is incorrect because raising the head is not standard positioning for this procedure.

Correct Answer: D

Rationale: The correct answer is D. Immediate recognition of respiratory distress is vital in clients with influenza, especially those at risk of complications. A (airborne precautions) is unnecessary unless the client is immunocompromised. B (complete bed rest) is outdated practice. C (oxygen administration) is only needed if hypoxia is present.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Take vital signs and pulse oximetry reading every 4 hours. This task is appropriate for delegation to an experienced nursing assistant because it involves routine monitoring that does not require advanced clinical judgment. Vital signs and pulse oximetry readings are essential in assessing a client's respiratory status and can provide valuable data for the healthcare team to make informed decisions. Option A, assessing the client's respiratory status every 4 hours, involves a higher level of assessment that requires nursing knowledge and clinical judgment, making it unsuitable for delegation to a nursing assistant. Option C, checking ventilator settings, is a critical task that involves ensuring the machine is correctly set up to support the client's breathing and should only be performed by a qualified healthcare professional. Option D, observing the client's need for suctioning every 2 hours, also requires a certain level of clinical judgment to determine when suctioning is necessary. This task involves assessing the client's respiratory secretions and deciding on the appropriate intervention, which should be done by a licensed nurse. Educationally, understanding the principles of delegation is crucial for healthcare professionals to provide safe and efficient care. Delegation is about entrusting the right tasks to the right person based on their competency levels. By mastering delegation principles, healthcare providers can optimize workflow, improve patient outcomes, and promote effective teamwork within the healthcare setting.

Correct Answer: D

Rationale: The correct answer is D) Arrange for directly observed therapy by a responsible family member or a public health nurse. This option is the best course of action because directly observed therapy (DOT) ensures medication adherence by having a responsible individual observe the patient taking their medication. This method is highly effective in cases of noncompliance, like in this scenario where the patient is struggling to remember to take their medication consistently. Option A is not the best choice because simply bringing the patient to the clinic daily does not guarantee that they will take the medication as prescribed when they are not at the clinic. Option B may provide motivation but does not address the immediate need for ensuring medication compliance. Option C focuses on educating the patient about the risks of noncompliance, but in this case, the patient is already aware of the risks and needs more practical support. In an educational context, it is crucial for healthcare providers to understand the challenges patients face in adhering to treatment plans. By utilizing strategies like directly observed therapy, healthcare professionals can support patients in overcoming barriers to adherence and improve treatment outcomes in conditions like TB that require strict medication regimens for successful management.