The client is prescribed a long-acting beta2 agonist and expresses concerns about the cost, stating they only use the inhaler during asthma attacks. How should the nurse respond?

Correct Answer: B

Rationale: Step 1: The nurse must acknowledge the client's concern about the cost of the inhaler. Step 2: Suggesting community services shows empathy and addresses the financial aspect. Step 3: Encouraging daily use aligns with the standard treatment guidelines. Step 4: By addressing both cost and importance of daily use, the nurse promotes adherence and support. Summary of other choices: A: Incorrect. This option doesn't address the client's financial concerns. C: Incorrect. Focusing on fears of breathlessness doesn't directly address the client's cost concern. D: Incorrect. While discussing daily use is important, not directly addressing the cost concern may lead to non-adherence.

Correct Answer: A

Rationale: The correct answer is A: Assess the client's oxygen saturation. This is the priority because the client's puffy face and swollen eyelids may indicate airway obstruction or respiratory distress, common complications in tracheostomy patients. Assessing oxygen saturation helps determine if the client is getting enough oxygen. Option B (Notify the Rapid Response Team) is not the immediate action unless the client's condition deteriorates rapidly. Option C (Oxygenate the client with a bag-valve-mask) may be necessary but should come after assessing oxygen saturation. Option D (Palpate the skin of the upper chest) is irrelevant to the client's current symptoms.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Tracheostomy cuff should be inflated to prevent aspiration. 2. Food particles indicate cuff leakage. 3. Measuring cuff pressure ensures proper sealing. 4. Prevents aspiration and respiratory complications. Summary: A: Elevating the head is beneficial but doesn't address cuff leakage. C: NPO status is extreme and unnecessary without confirmation of aspiration risk. D: Swallow study is for assessing swallowing function, not related to cuff pressure.

Correct Answer: A

Rationale: The correct answer is A: Assess the client's lung sounds. This action takes priority because the client experienced a coughing spell, indicating a potential aspiration risk. Assessing lung sounds can help determine if there is any respiratory distress or compromised airway. B: Assigning a different UAP does not address the immediate concern of the client's respiratory status. C: Reporting the UAP to the manager may be necessary but is not the immediate priority when the client's health is at risk. D: Requesting thicker liquids for meals does not address the client's current condition and may not be appropriate without proper assessment.

Correct Answer: C

Rationale: The correct answer is C: Tying a square knot at the back of the neck. The reason this action requires intervention is that a square knot is not recommended for securing tracheostomy ties as it can be difficult to untie in an emergency. Instead, a quick-release knot or Velcro closure is typically used for easy removal. A: Holding the device securely when changing ties is important for maintaining the integrity of the tracheostomy. B: Suctioning the client first if secretions are present is a standard practice to ensure clear airways. D: Using half-strength peroxide for cleansing is appropriate for tracheostomy care to prevent infection. In summary, the incorrect choice is C because tying a square knot can pose risks in an emergency situation, while the other choices are appropriate actions in tracheostomy care.