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 B (complete bed rest) is outdated practice.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: 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.