Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?

Correct Answer: B

Rationale: The correct answer is B: Impaired gas exchange. This is the priority nursing diagnosis for a patient with a traumatic brain injury and a tracheostomy because it directly affects the patient's oxygenation and ventilation, which are essential for sustaining life. Impaired gas exchange can lead to hypoxia and respiratory distress, requiring immediate intervention to ensure adequate oxygenation. Choice A, Risk for skin breakdown, is important but not the priority as it can be managed with proper positioning and skin care. Choice C, Ineffective airway clearance, is related to the tracheostomy but is not the priority over ensuring adequate gas exchange. Choice D, Risk for infection, is also important but does not take precedence over addressing impaired gas exchange, which is critical for the patient's immediate well-being.

Correct Answer: B

Rationale: The correct answer is B: Raise the head of the bed. Elevating the client's head helps improve ventilation and oxygenation by facilitating better lung expansion. This intervention can help enhance oxygen exchange, which is crucial for a client with pneumonia and low oxygen saturation. Increasing the oxygen flow rate (choice A) may be necessary but should not be the first intervention. Notifying the healthcare provider (choice C) is important but not the immediate priority. Encouraging deep breathing exercises (choice D) can be beneficial but may not address the immediate need for improved oxygenation.

Correct Answer: A

Rationale: The correct answer is A because a PaO2/FiO2 ratio of 200 indicates severe hypoxemia in ARDS, signifying impaired gas exchange and poor oxygenation. This ratio is a key indicator of the severity of ARDS. B: Bilateral infiltrates on chest X-ray are expected findings in ARDS but do not directly reflect the severity of hypoxemia. C: A pH of 7.45 in ABG suggests normal acid-base balance, which is not as concerning as severe hypoxemia. D: A serum lactate level of 2 mmol/L is within the normal range and is not specific to ARDS or indicative of its severity.

Correct Answer: B

Rationale: The correct answer is B: Placing the client in high Fowler's position. This is the priority intervention for a client with acute respiratory failure as it helps improve lung expansion and oxygenation by maximizing chest expansion. Administering a bronchodilator (Choice A) may help with airway patency but placing the client in an upright position takes precedence. Preparing the client for intubation (Choice C) is a more invasive intervention and should be considered after optimizing non-invasive measures. Administering IV antibiotics (Choice D) may be necessary but addressing the immediate respiratory distress by positioning the client correctly is the priority.

Correct Answer: C

Rationale: The correct answer is C: Using an N95 respirator while providing care. This is because TB is an airborne disease that can spread through respiratory droplets. The N95 respirator provides the highest level of protection against inhaling these droplets. A: Wearing a surgical mask is not sufficient to protect against TB transmission as it does not filter out small infectious particles. B: Hand hygiene is important for infection control but does not specifically address airborne transmission of TB. D: Gowning and gloving may be necessary for contact precautions but do not provide adequate protection against airborne transmission of TB.