A patient with a tracheostomy tube cannot cough up secretions effectively. What should the nurse do next?

Correct Answer: C

Rationale: The correct answer is C: Use sterile gloves and perform suctioning. This is the appropriate action to help the patient with a tracheostomy tube who cannot cough up secretions effectively. Suctioning helps clear the airway of secretions and prevents complications such as respiratory distress. Encouraging the use of an incentive spirometer (A) is not effective in clearing secretions directly. Promoting increased oral fluid intake (B) may not address the immediate need for clearing secretions. Preoxygenating the patient (D) before suctioning is not the next step but rather a precautionary measure during the suctioning process.

Correct Answer: D

Rationale: The correct answer is D because providing emotional support and monitoring vital signs are essential roles for the nurse during a thoracentesis procedure. Emotional support helps to reduce anxiety and promote patient comfort. Monitoring vital signs ensures patient safety and early detection of any complications. Choice A (monitor oxygen saturation continuously) is not typically necessary during a thoracentesis unless the patient is at high risk for respiratory compromise. Choice B (instruct the patient to hold their breath) is incorrect as the patient is usually instructed to breathe normally or take shallow breaths during the procedure to minimize movement. Choice C (position the patient on the affected side) is also incorrect as the patient is typically positioned sitting upright or slightly leaning forward to facilitate access to the pleural space.

Correct Answer: A

Rationale: The correct answer is A: Avoid eating or drinking for 6-8 hours before the procedure. This instruction is crucial to prevent aspiration during bronchoscopy. Eating or drinking can lead to vomiting, which poses a risk during the procedure. Choice B is incorrect as some medications may need to be avoided before the procedure. Choice C is incorrect as chest discomfort is not expected during the procedure. Choice D is incorrect as deep breathing exercises are not typically required before bronchoscopy.

Correct Answer: A

Rationale: The correct answer is A: Performing oral care with chlorhexidine. This intervention is most effective for preventing VAP because it helps reduce the colonization of pathogenic bacteria in the oral cavity, which can be aspirated into the lungs. Chlorhexidine is an antiseptic agent that can effectively reduce the risk of developing pneumonia. Summary of other choices: B: Changing ventilator tubing every shift - While maintaining clean ventilator tubing is important for infection prevention, it is not the most effective intervention for preventing VAP. C: Suctioning the patient hourly - Frequent suctioning may be necessary for airway clearance, but it is not specifically targeted at preventing VAP. D: Keeping the patient sedated continuously - Continuous sedation may lead to complications such as prolonged ventilation and increased risk of pneumonia. It is not a recommended strategy for preventing VAP.

Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound typically heard on inspiration, indicating upper airway obstruction. This finding requires immediate intervention as it can lead to airway compromise and respiratory distress. Explanation for why other choices are incorrect: B: Cough productive of yellow sputum may indicate a respiratory infection but does not necessarily require immediate intervention. C: Oxygen saturation of 92% on 2 L/min oxygen is concerning but not immediately life-threatening. It may require adjustment of oxygen therapy. D: Respiratory rate of 20 breaths per minute falls within the normal range and does not indicate immediate intervention is needed.