The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Correct Answer: C

Rationale: In this scenario, option C is the correct answer. When coarse crackles are heard in a patient with a tracheostomy tube and they are unable to cough up secretions, suctioning is necessary to clear the airway and prevent respiratory complications. Using a sterile catheter to suction helps remove the secretions effectively. Option A, encouraging increased incentive spirometer use, is incorrect because it focuses on lung expansion rather than directly addressing the need for clearing secretions. Option B, encouraging increased oral fluid intake, is also incorrect as it does not address the immediate need for airway clearance. Option D, preoxygenating the patient before suctioning, is not the priority action when the patient is having difficulty clearing secretions. Educationally, this question highlights the importance of prompt and effective airway management in patients with tracheostomy tubes, especially when abnormal breath sounds are present. Nurses must be adept at recognizing respiratory distress signs and taking appropriate action to maintain airway patency and oxygenation. Mastering these skills is crucial for nurses caring for patients with compromised respiratory function.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Explain that this is a normal side effect of the medication. This response is correct because the orange discoloration of bodily fluids is a known side effect of the medication used to treat tuberculosis, specifically rifampin. It is important for the nurse to educate the patient about this side effect to alleviate any concerns and ensure medication adherence. Option A) Discontinuing the medication immediately is not necessary in this case because the orange discoloration is not a sign of a serious adverse reaction requiring immediate cessation of treatment. Option B) Reporting the finding to the healthcare provider may not be needed as this side effect is well-documented and does not typically require medical intervention. Option D) Checking for signs of an allergic reaction is not warranted as the orange discoloration is a known non-allergic side effect of the medication. Educationally, this question highlights the importance of understanding common side effects of medications used in the treatment of tuberculosis. Nurses need to be knowledgeable about medication side effects to provide accurate information and support to patients undergoing treatment. It also emphasizes the need for patient education to address concerns and promote medication adherence.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Decreased use of accessory muscles during exhalation. Pursed-lip breathing is a technique commonly used to improve breathing efficiency in patients with COPD by prolonging exhalation, preventing airway collapse, and promoting better gas exchange. When a patient with COPD effectively uses pursed-lip breathing, they experience decreased respiratory effort and reduced reliance on accessory muscles to breathe, leading to improved ventilation and oxygenation. Option B) Increased respiratory rate to 22 breaths per minute is incorrect because an increased respiratory rate may indicate respiratory distress or inadequate gas exchange, which is not a sign of improved breathing in this context. Option C) Oxygen saturation remaining at 88% is incorrect because although oxygen saturation is an important parameter to monitor in COPD patients, it alone does not indicate the effectiveness of pursed-lip breathing. Oxygen saturation may remain the same even if breathing efficiency has improved. Option D) Improved breath sounds bilaterally is incorrect because while improved breath sounds can be a positive sign, they do not directly indicate the effectiveness of pursed-lip breathing in a patient with COPD. It is more important to focus on the patient's respiratory effort and use of accessory muscles to assess the impact of the breathing technique. In an educational context, understanding the rationale behind the correct answer reinforces the importance of therapeutic breathing techniques like pursed-lip breathing in managing COPD. It highlights the goal of reducing respiratory work and improving gas exchange in these patients. Additionally, differentiating between the options helps students develop critical thinking skills and clinical reasoning abilities when evaluating patient responses to interventions.

Correct Answer: B

Rationale: In the context of caring for a patient with suspected pneumonia, the most appropriate initial diagnostic test to perform is a chest x-ray (option B). This is because a chest x-ray can provide quick and valuable information about the presence of infiltrates, consolidation, or other abnormalities in the lungs that are indicative of pneumonia. Identifying these findings promptly can guide timely treatment decisions and help in monitoring the progression of the disease. Regarding the other options: A) Complete blood count (CBC) may provide information about white blood cell counts, which can be elevated in the presence of infection, but it does not directly visualize lung abnormalities. C) Arterial blood gas (ABG) analysis can assess oxygenation and acid-base status but is not the primary test for diagnosing pneumonia. D) Sputum culture is important for identifying the specific pathogen causing pneumonia but is usually not the initial test performed. In an educational context, understanding the rationale behind selecting the most appropriate diagnostic test is crucial for nursing practice. It helps students develop critical thinking skills to prioritize care, make sound clinical judgments, and provide evidence-based interventions. By grasping the significance of diagnostic tests in specific clinical scenarios, nurses can enhance patient outcomes through accurate and timely diagnosis and treatment.

Correct Answer: B

Rationale: The correct answer is B) Performing oral care with chlorhexidine. Ventilator-associated pneumonia (VAP) is a common complication in mechanically ventilated patients due to the risk of aspiration and colonization of bacteria in the oral cavity. Performing oral care with chlorhexidine helps reduce the bacterial load in the mouth, decreasing the risk of VAP. Administering prophylactic antibiotics (Option A) is not recommended for VAP prevention due to concerns about antimicrobial resistance and the potential for selecting resistant organisms. Suctioning the airway every 2 hours (Option C) is important for airway clearance but is not the most effective intervention for preventing VAP. Over-suctioning can lead to mucosal damage and increased risk of infection. Keeping the patient sedated (Option D) may help with ventilator synchrony but does not directly address the prevention of VAP. Educationally, understanding the rationale behind each intervention is crucial for nurses and healthcare providers caring for mechanically ventilated patients. Emphasizing evidence-based practices like oral care with chlorhexidine can improve patient outcomes and reduce the incidence of complications like VAP.