While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging

Correct Answer: A

Rationale: The correct answer is A: What is the nurse's first nursing action? In this scenario, the nurse's first priority is to assess the patient's airway and breathing. By asking "What is the nurse's first nursing action?" the nurse can quickly assess the situation and determine if further intervention is needed. Choice B (Press the emergency response button) is incorrect as it does not address the immediate need to assess the patient's airway. Choice C (Place the patient on a face mask delivering 100% oxygen) is incorrect as it assumes the patient's airway is compromised and does not address the need to assess first. Choice D (Insert a spare tracheostomy without the obturator) is also incorrect as this action should only be taken if the tracheostomy tube is completely dislodged and the nurse has assessed that it is necessary.

Correct Answer: B

Rationale: The correct answer is B because the ABG results show respiratory acidosis (low pH) with hypoxemia (low PaO2) and hypercapnia (high PaCO2), indicating acute respiratory failure. Immediate intervention is needed to improve oxygenation and ventilation to prevent further deterioration. Choices A, C, and D do not show significant abnormalities requiring immediate intervention. A has slightly low PaO2 but normal pH and PaCO2. C has normal ABG values. D shows respiratory alkalosis with normal oxygenation and ventilation.

Correct Answer: C

Rationale: Rationale for Correct Answer C: Performing frequent oral care is the most effective intervention in preventing hospital-acquired pneumonia. This is because oral care helps to reduce the risk of oral bacteria being aspirated into the lungs, which can lead to pneumonia. By keeping the mouth clean and free of harmful bacteria, the risk of pneumonia is significantly reduced. Summary of Incorrect Choices: A: Administering antibiotics as prescribed may be necessary for treating pneumonia, but it does not directly prevent hospital-acquired pneumonia. B: Encouraging ambulation several times daily is important for preventing complications like deep vein thrombosis in hospitalized patients, but it does not directly prevent pneumonia. D: Providing a high-calorie, high-protein diet is important for overall nutrition and immune function, but it does not directly prevent hospital-acquired pneumonia.

Correct Answer: A

Rationale: The correct answer is A: Productive cough with pink, frothy sputum. This finding indicates potential pulmonary edema, a life-threatening condition. Pink, frothy sputum suggests blood-tinged fluid in the lungs, requiring immediate intervention. Options B and C are concerning but can be managed with timely interventions. Option D is within the normal range for respiratory rate and does not indicate immediate danger.

Correct Answer: B

Rationale: The correct answer is B: Administer a prescribed NSAID. NSAIDs are commonly used to manage pain associated with pleurisy by reducing inflammation and relieving discomfort. Deep breathing exercises (choice A) may worsen pain due to increased movement of the chest wall. Positioning the client flat on the back (choice C) may exacerbate pain by putting pressure on the affected area. Restricting fluid intake (choice D) is not indicated for pain management in pleurisy. Administering NSAIDs is the most appropriate intervention to address the underlying cause of pain in pleurisy.