The nurse is caring for a client with pneumothorax who has a chest tube. What intervention should the nurse prioritize?

Correct Answer: C

Rationale: The correct answer is C: Keeping the drainage system below the chest level. This is crucial to ensure proper drainage and prevent air from entering the pleural space. Placing the system below the chest level allows gravity to assist in drainage. Choice A is incorrect because ambulation may increase the risk of dislodging the chest tube. Choice B is incorrect as clamping the chest tube can lead to tension pneumothorax. Choice D is incorrect as changing the chest tube dressing daily is not a priority over maintaining proper positioning of the drainage system.

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: Immediate relief of bronchospasm. Short-acting beta-agonists like albuterol act quickly to dilate the airways, providing immediate relief of bronchospasm in COPD by relaxing the smooth muscles in the lungs. This effect helps improve airflow and alleviate symptoms such as shortness of breath and wheezing. Reduction in mucus production (choice A) is typically targeted by medications like mucolytics, not beta-agonists. Prevention of airway inflammation (choice C) is usually achieved with corticosteroids. Increased oxygen absorption in the lungs (choice D) is not a direct effect of short-acting beta-agonists.

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.