What is the proper hand position when performing chest vibration?

Correct Answer: B

Rationale: The correct hand position for performing chest vibration is to spread the fingers. This allows for a larger surface area of contact with the chest, promoting effective transmission of vibrations to loosen chest secretions. Flattening the hands would reduce the effectiveness of the vibrations by limiting contact area. Cupping the hands creates a smaller contact area and may concentrate the pressure too much in one spot, potentially causing discomfort or injury. Therefore, spreading the fingers is the optimal hand position for chest vibration technique.

Correct Answer: A

Rationale: The correct answer is A: Provide tracheostomy care. This is the priority because maintaining the patency of the airway is crucial in a client with a tracheostomy. Tracheostomy care includes monitoring for any signs of respiratory distress, ensuring the tube is secure, assessing for any obstructions, and providing appropriate humidification. Suctioning the airway (choice B) and suctioning the tracheostomy (choice D) are important interventions but come after ensuring proper tracheostomy care. Changing the dressing (choice C) is also important but not as immediate as ensuring the airway remains clear and functional.

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy. For a client with shortness of breath and a history of heart failure, oxygen therapy is the most effective intervention as it helps improve oxygenation and relieve respiratory distress. Administering diuretics may help manage fluid retention but does not directly address the breathing difficulty. Encouraging deep breathing may be beneficial for some respiratory conditions but may not be sufficient for a client with heart failure and shortness of breath. Applying oxygen therapy is similar to providing oxygen therapy and can help improve oxygen levels, but providing oxygen therapy is more specific and effective in this case.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the spine. This is the most appropriate intervention for a client with a suspected spinal cord injury to prevent further damage. Immobilization helps stabilize the spine and reduce the risk of spinal cord compression or injury. Administering pain relief (B) or IV fluids (C) should only be done after proper spinal immobilization to avoid exacerbating the injury. Placing the client in a supine position (D) can be beneficial if done carefully after spine immobilization, but immobilizing the spine takes precedence to prevent any potential movement that could worsen the injury.

Correct Answer: D

Rationale: The correct answer is D. When a client refuses medication, the nurse should document the refusal for legal and communication purposes. Informing the healthcare provider ensures ongoing assessment and potential alternatives. Choice A lacks communication with the healthcare team. Choice B may not address the underlying issue. Choice C assumes alternative treatment is necessary without further evaluation.