A nurse is caring for a patient with a history of chronic kidney disease (CKD). The patient is experiencing fluid retention. What is the priority nursing action?

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps to relieve fluid retention by promoting diuresis through the dilation of blood vessels. Step 1: Assess the patient's condition and identify fluid retention as an issue. Step 2: Administer albuterol as it helps to reduce fluid volume by increasing urine output. Step 3: Monitor the patient for improvement in fluid status. Other choices are incorrect because B: Monitoring blood pressure is important but not the priority in this case. C: Administering IV fluids would worsen fluid retention. D: Administering antihypertensive medications may not directly address the fluid retention issue.

Correct Answer: C

Rationale: In the context of a patient with a tracheostomy receiving a new order for a fenestrated tracheostomy tube, assessing the ability to swallow before using the fenestrated tube is crucial. Option C is correct because fenestrated tubes are designed to allow for improved speech and facilitate swallowing by directing airflow through the upper airway, which is essential for preventing aspiration. Option A is incorrect because leaving the tracheostomy inner cannula inserted at all times does not address the specific benefits of a fenestrated tube related to speech and swallowing. Option B is incorrect as placing the decannulation cap in the tube before cuff deflation is not directly related to the function of the fenestrated tube in improving swallowing ability. Option D is also incorrect because inflating the tracheostomy cuff during the use of the fenestrated tube would hinder the benefits of the fenestrated design in promoting improved speech and swallowing. Educationally, understanding the rationale behind the use of fenestrated tracheostomy tubes and the importance of assessing swallowing ability before their use enhances a nurse's ability to provide safe and effective care to patients with tracheostomies. It highlights the significance of individualized care and proper collaboration with other healthcare professionals, such as speech therapists, to optimize patient outcomes.

Correct Answer: B

Rationale: In the context of preventing aspiration in a high-risk patient, placing a patient with altered consciousness in a side-lying position (Option B) is the correct action. This position helps to reduce the risk of aspiration by preventing gastric contents from entering the airway. When a patient is in a side-lying position, gravity helps to keep the airway clear and reduces the likelihood of aspiration pneumonia. Option A is incorrect because while turning and repositioning an immobile patient every 2 hours is important for preventing pressure ulcers and maintaining skin integrity, it does not directly address the risk of aspiration in a high-risk patient. Option C is incorrect as inserting a nasogastric tube for feeding a patient with high calorie needs may be a necessary intervention for nutritional support but does not specifically address the prevention of aspiration. Option D is also incorrect as monitoring respiratory symptoms in an immunosuppressed patient is important for detecting infections early but does not directly address preventing aspiration in a high-risk patient. Educationally, understanding the rationale behind positioning strategies for patients with altered consciousness is crucial for nurses to provide safe and effective care. It is essential for nurses to grasp the significance of proper positioning in reducing aspiration risks, especially in vulnerable patient populations. This knowledge enhances patient safety and quality of care provided by healthcare professionals.

Correct Answer: D

Rationale: The correct answer is option D: "I will call the health care provider right away if I develop a fever." This response indicates effective teaching because post-lung transplant patients are at a high risk of infections and rejection. A fever can be an early sign of these serious complications, and prompt reporting is crucial for timely intervention. Option A is incorrect because seeing the doctor only once a year is not sufficient for post-lung transplant care, which requires more frequent monitoring and follow-up. Option B is incorrect as stopping prednisone abruptly can lead to rejection or exacerbate the condition, so it is not advisable to discontinue the medication without medical guidance. Option C is also incorrect because feeling short of breath with exercise should not be ignored post-transplant. It could be a sign of complications or inadequate oxygenation, and patients should be encouraged to report any changes in their breathing pattern to their healthcare provider promptly. Educationally, this question assesses the learner's understanding of the unique care needs of post-lung transplant patients. It reinforces the importance of patient education on recognizing and reporting potential complications early to ensure optimal outcomes and prevent serious consequences. By choosing the correct answer, learners demonstrate their grasp of the critical aspects of post-transplant care and the significance of vigilant monitoring and immediate reporting of symptoms.

Correct Answer: C

Rationale: This appears to be a partial question combined with the next one. Assuming it relates to inhaler use, the correct technique does not involve removing the mask when misting stops or activating at expiration. For the next question on spirometry, withholding bronchodilators (C) is correct to ensure accurate baseline lung function.