The nurse is caring for a client with a tracheostomy. Which intervention is the priority?

Correct Answer: B

Rationale: The correct answer is B: Ensuring a replacement tracheostomy tube is at the bedside. This is the priority because in the event of accidental dislodgement or obstruction of the current tracheostomy tube, a replacement must be readily available to maintain the client's airway. Without a replacement tube, the client could experience severe respiratory distress or even airway obstruction, which could be life-threatening. Cleaning the stoma site every 24 hours (Choice A) is important for hygiene but is not the immediate priority. Suctioning the tracheostomy every 8 hours (Choice C) is a routine maintenance task and should be done as needed based on assessment. Providing humidified oxygen through the tracheostomy (Choice D) is important for maintaining proper oxygenation but ensuring a replacement tube takes precedence to maintain airway patency.

Correct Answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position can improve oxygenation by optimizing ventilation-perfusion matching and reducing the risk of ventilator-induced lung injury. This position helps to redistribute lung perfusion and improve ventilation in the dependent lung regions. It also helps to prevent atelectasis and promote better gas exchange. Administering high-flow oxygen via nasal cannula (A) may not be as effective in severe cases of ARDS. Performing frequent oral suctioning (C) can potentially worsen oxygenation by causing hypoxemia due to suction-induced atelectrauma. Increasing the respiratory rate on the ventilator (D) without addressing the underlying lung injury may not effectively improve oxygenation and can lead to further lung damage.

Correct Answer: B

Rationale: The correct answer is B because during an acute situation like respiratory distress, the nurse should prioritize gathering specific information about the current episode to assess the severity and potential causes promptly. This allows for timely interventions and prevents further complications. Choices A, C, and D are incorrect because: A - It is not appropriate to ask the patient to lie down immediately without gathering vital information first. C - Checking for allergies is important but not the priority in an acute situation. D - Delaying the physical assessment for pulmonary function tests can lead to a delay in providing necessary interventions.

Correct Answer: C

Rationale: The correct answer is C: Assist the patient to splint the chest when coughing. This action helps stabilize the chest wall, allowing better force generation during coughing to assist in clearing the airways. Restricting oral fluids (A) would not promote airway clearance. Teaching pursed-lip breathing (B) is beneficial for some respiratory conditions but not specifically for clearing thick sputum. Encouraging the patient to wear a nasal O2 cannula (D) is important for oxygenation but does not directly aid in airway clearance.

Correct Answer: C

Rationale: The correct answer is C: Hold the breath for 10 seconds after inhalation. This instruction is important for ensuring proper medication delivery to the lungs. Holding the breath allows the medication to reach deeper into the lungs. Option A is incorrect because DPIs should not be shaken. Option B is incorrect as exhaling into the inhaler can lead to contamination. Option D is incorrect because rinsing the mouth is typically advised for using corticosteroid inhalers, not DPIs. Holding the breath is crucial for optimal drug deposition in the lungs.