An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse is to choose option A: Assess the client's lung sounds. Coughing during feeding in a client with a tracheostomy can indicate aspiration, which is a serious concern as it can lead to respiratory compromise. Assessing the client's lung sounds will provide crucial information about the client's respiratory status and whether any aspiration has occurred. Option B: Assign a different AP to the client is incorrect because the priority is to assess the client's condition first before making any staffing changes. Option C: Report the AP to the manager is also incorrect as it does not address the immediate need to assess the client's respiratory status. Option D: Request thicker liquids for meals is incorrect because in this case, the client's coughing spell indicates a potential aspiration risk, so changing the consistency of the liquids may not address the underlying issue. Educationally, this question emphasizes the importance of prompt assessment and intervention when a client with a tracheostomy experiences a coughing spell during feeding. It highlights the significance of recognizing signs of aspiration and the need for timely nursing actions to ensure the client's safety and well-being. Understanding the rationale behind the correct answer reinforces critical thinking skills and clinical judgment in providing care for clients requiring oxygen therapy.

Correct Answer: C

Rationale: In the scenario of a woman with preeclampsia experiencing a seizure, the priority action for the nurse is to administer oxygen by mask (Option C). This is the correct answer because during a seizure, the body's demand for oxygen increases significantly. Providing oxygen by mask ensures that the patient receives an adequate supply of oxygen to prevent hypoxia and maintain oxygenation to vital organs, including the brain. Inserting an oral airway (Option A) is not the priority in this situation because maintaining oxygenation is more critical during a seizure. An oral airway may be considered once the seizure has subsided to help maintain a clear airway. Suctioning the mouth to prevent aspiration (Option B) is also not the priority during an active seizure. While preventing aspiration is important, ensuring oxygenation takes precedence in this emergency situation. Calling the physician immediately (Option D) is not the priority action during an active seizure. The immediate focus should be on providing essential care to the patient to stabilize their condition. Once the patient is stable, the nurse can involve the physician as needed. Educationally, this question highlights the importance of prioritizing care during emergency situations, such as seizures in patients with preeclampsia. Nurses must be able to quickly assess and intervene to address the most critical needs of the patient to ensure positive outcomes. Understanding the rationale behind the priority actions in such scenarios is essential for providing safe and effective care in clinical practice.

Correct Answer: B

Rationale: In the context of a client with acute respiratory distress syndrome (ARDS), the priority nursing diagnosis is Impaired Spontaneous Ventilation (B). This is because ARDS is characterized by severe respiratory compromise, necessitating immediate interventions to maintain adequate oxygenation. Impaired Spontaneous Ventilation directly addresses the primary issue of respiratory distress in ARDS, making it crucial to prioritize this nursing diagnosis. The other options are not the priority in this scenario because: A) Risk for Infection: While infection is a potential complication in ARDS due to compromised lung function, it is secondary to the immediate threat of inadequate oxygenation. Treating the underlying ventilation issue takes precedence over preventing potential future infections. C) Risk for Acute Confusion: While patients with ARDS may experience altered mental status due to hypoxemia, addressing their respiratory distress is more critical in the immediate term to ensure adequate oxygen supply to vital organs. D) Decreased Cardiac Output: While ARDS can lead to systemic complications, such as decreased cardiac output, addressing the primary respiratory issue is paramount to improve oxygenation and prevent further deterioration. In an educational context, understanding the priority nursing diagnosis in ARDS highlights the significance of timely interventions in managing respiratory emergencies. Nurses need to prioritize interventions that directly address the most life-threatening issues to optimize patient outcomes. By focusing on Impaired Spontaneous Ventilation as the priority diagnosis in ARDS, nurses can effectively target the critical need for oxygenation support in these high-acuity situations.

Correct Answer: C

Rationale: In the context of a client with COPD secondary to emphysema, the correct answer is option C) Barrel chest. This is because a barrel chest is a classic physical manifestation seen in individuals with emphysema due to the chronic air trapping and lung hyperinflation that occurs in this condition. The overinflation of the lungs leads to a characteristic increase in the anteroposterior diameter of the chest, resulting in a barrel-shaped appearance. Option A) Tachycardia is not typically a direct clinical manifestation of emphysema or COPD. While individuals with COPD may experience tachycardia as a result of hypoxia or exacerbations, it is not a specific hallmark of emphysema. Option B) Cough is a common symptom in COPD; however, it is not specific to emphysema and can be present in various respiratory conditions. Option D) Wheezing is more commonly associated with asthma or bronchospasm rather than emphysema. Wheezing is caused by narrowing of the airways, which is not the primary pathology in emphysema. Understanding the characteristic clinical manifestations of COPD, such as a barrel chest in emphysema, is crucial for nurses caring for these patients. Recognizing these signs aids in accurate assessment, diagnosis, and management of COPD, ultimately promoting optimal patient outcomes. By linking theoretical knowledge with clinical practice, nurses can provide comprehensive care and support to individuals with COPD.

Correct Answer: C

Rationale: The correct answer to the question is C) Native American infants. This population, including Alaskan Natives, is at the highest risk of RSV hospitalization due to a combination of genetic and environmental factors. Native American infants often live in crowded conditions, have limited access to healthcare, and are more likely to have underlying health conditions that predispose them to severe respiratory infections like RSV. Additionally, genetic factors may play a role in their increased susceptibility to RSV. Option A) Alaskan Native infants is incorrect because while they are included in the high-risk Native American population, the question specifically asks for the highest risk group, which encompasses a broader category. Option B) African American infants and Option D) Asian American infants are incorrect because while they may be at increased risk compared to the general population, they do not have as high a risk of RSV hospitalization as Native American infants. Educationally, understanding the population-specific risks associated with RSV is crucial for nurses caring for pediatric clients. By recognizing which groups are at the highest risk, nurses can implement appropriate preventive measures, provide targeted education to families, and ensure timely interventions to reduce the likelihood of hospitalization and complications associated with RSV. This knowledge is essential for providing safe and effective care to pediatric patients, especially during the respiratory virus season.