A client receiving oxygen therapy via nasal cannula reports nasal dryness. What is the nurse's best response?

Correct Answer: B

Rationale: In this scenario, the best response for the nurse when a client receiving oxygen therapy via nasal cannula reports nasal dryness is option B) Apply water-soluble lubricant to the nostrils. The rationale behind choosing this option is that nasal dryness is a common side effect of oxygen therapy through a nasal cannula due to the drying effect of the oxygen flow. Applying a water-soluble lubricant helps to moisturize the nasal passages, alleviating dryness and discomfort for the client. Option A is incorrect because increasing the oxygen flow rate can exacerbate nasal dryness rather than alleviate it. It may lead to further discomfort and potential harm to the nasal mucosa. Option C suggests switching to a simple face mask, which is not necessary if the issue is only nasal dryness. Face masks may not be well tolerated by all clients and can be uncomfortable for prolonged use. Option D is not the best response as encouraging the client to breathe through their mouth does not address the underlying issue of nasal dryness caused by oxygen therapy. Moreover, mouth breathing may not be as effective in oxygen delivery for some individuals. Educationally, this question highlights the importance of assessing and managing side effects of oxygen therapy, promoting critical thinking in nursing interventions, and understanding the rationale behind each response to provide safe and effective care for clients undergoing oxygen therapy.

Correct Answer: A

Rationale: In the context of a client with pneumonia prescribed antibiotics, the priority nursing intervention is administering the antibiotics on time (Option A). This is crucial because timely administration ensures that the prescribed treatment is effective in combating the infection and preventing its spread. Encouraging the client to complete the full course of antibiotics (Option B) is important for preventing antibiotic resistance and ensuring complete eradication of the infection. However, in terms of immediate priority, timely administration takes precedence. Monitoring for signs of allergic reaction after administration (Option C) is essential for client safety but is not the immediate priority compared to ensuring the administration of the prescribed treatment. Documenting the client's response to treatment (Option D) is important for tracking progress and evaluating the effectiveness of the antibiotics. However, this falls secondary to the critical need for timely administration to address the active infection promptly. In an educational context, understanding the rationale behind prioritizing interventions helps nurses develop critical thinking skills necessary for making quick and effective decisions in clinical practice. Emphasizing the significance of timely medication administration underscores the importance of adherence to treatment protocols to achieve positive patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Collecting a sputum culture. The priority for a client with pneumonia exhibiting a productive cough and fever is to identify the causative organism through a sputum culture. This will guide appropriate antibiotic therapy, crucial for effective treatment of pneumonia. Option A (Encouraging fluid intake) is important for maintaining hydration but is not the priority when the client's condition requires immediate intervention for diagnosis and treatment. Option B (Administering antipyretics) addresses the fever symptomatically but does not address the underlying cause. Option C (Performing chest physiotherapy) may be beneficial in mobilizing secretions but is not the priority over identifying the infectious agent causing the pneumonia. Educationally, this question highlights the importance of critical thinking in prioritizing interventions based on the client's condition and the urgency of the situation. It emphasizes the significance of diagnostic procedures in guiding appropriate treatment and the role of nurses in clinical decision-making to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, option C is the correct answer because a decreased respiratory rate from 30 to 20 breaths per minute indicates improved oxygenation and respiratory status in a client with pneumonia. As the client's breathing becomes more efficient, the need for oxygen therapy decreases, reflecting a positive response to treatment. Option A is incorrect as an oxygen saturation of 92% on room air is still below the desired range (typically 95% or higher) for a client receiving oxygen therapy. This indicates that the client still requires supplemental oxygen. Option B, a decrease in heart rate from 110 to 95 beats per minute, may be a positive finding, but it is not as specific to respiratory improvement as a decreased respiratory rate. Option D is incorrect as the client reporting fatigue after ambulating to the bathroom is not a direct indicator of respiratory improvement. It could be related to other factors such as deconditioning or infection. In an educational context, understanding the importance of vital sign assessment in monitoring a client's response to oxygen therapy is crucial for nurses. Changes in respiratory rate, oxygen saturation, heart rate, and client symptoms can provide valuable information about the effectiveness of treatment and guide further interventions. Recognizing these clinical cues is essential for delivering high-quality patient care.

Correct Answer: A

Rationale: In the context of a client with a tracheostomy at risk for aspiration, the nurse should prioritize providing thickened liquids with meals (Option A) as the correct intervention. Thickened liquids are recommended to reduce the risk of aspiration in individuals with swallowing difficulties or tracheostomies. Thickened liquids move more slowly, making them easier to control and swallow, decreasing the risk of liquid entering the airway. Suctioning the tracheostomy before meals (Option B) can help maintain airway patency but does not directly address the risk of aspiration during meals. Positioning the client flat during feeding (Option C) can increase the risk of aspiration as it promotes reflux and pooling of liquids in the throat. Encouraging the client to drink water with meals (Option D) can increase the risk of aspiration due to the thin consistency of water. In an educational context, it is crucial for nurses to understand the principles of safe feeding practices for clients with tracheostomies to prevent complications like aspiration pneumonia. By prioritizing the provision of thickened liquids, nurses can ensure the safety and well-being of clients with these specific care needs.