A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met?

Correct Answer: C

Rationale: Rationale: The correct answer is C because the ability to swallow own secretions without drooling indicates that the client's airway is patent and functional post modUPPP, a priority goal for this procedure. This assessment finding ensures that the client can maintain a clear airway and prevent complications such as aspiration. Incorrect choices: A: Although pain control is important, it is not a priority assessment for this specific procedure. B: Absence of foul odor or red mucus membranes is not directly related to the airway patency or swallowing ability. D: While normal vital signs are reassuring, they do not directly indicate the success of the surgery in improving airway function.

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 B (complete bed rest) is outdated practice.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.

Correct Answer: D

Rationale: The primary principle involved in the various airway clearance devices used for mobilizing secretions is positive expiratory pressure (PEP). PEP devices work by creating pressure in the airways during exhalation, helping to keep the airways open and mobilize secretions effectively. This mechanism facilitates the clearance of mucus and other secretions from the lungs, making it easier for individuals with respiratory conditions to breathe and maintain healthy lung function. Option A) Vibration: While vibration therapy can be used as a complementary technique in airway clearance, it is not the primary principle involved in most airway clearance devices. Vibration helps to loosen mucus in the airways but does not provide the sustained positive pressure needed for effective secretion mobilization. Option B) Inhalation therapy: Inhalation therapy involves the administration of medications via inhalation devices and is not directly related to airway clearance techniques. While inhalation therapy can help manage respiratory conditions, it does not focus on mobilizing secretions from the airways. Option C) Chest physiotherapy: Chest physiotherapy includes a range of techniques such as chest percussion and postural drainage, which are used to assist with airway clearance. While chest physiotherapy can be effective, the primary principle involved in airway clearance devices like PEP devices is the application of positive expiratory pressure during exhalation. Educational context: Understanding the principles behind airway clearance techniques is crucial for healthcare professionals working with patients who have respiratory conditions. Knowledge of how different airway clearance devices work helps in selecting the most appropriate treatment options for individual patients based on their condition and needs. By grasping the mechanisms of action of these devices, healthcare providers can optimize the management of respiratory conditions and improve patient outcomes.