A nurse is caring for a client who has a tracheostomy tube.
Upon data collection, the nurse observes the client is restless and hears crackles in the lungs.
Which of the following interventions should the nurse take?

Choice A rationale

Tomato soup contains minimal protein and is not a substantial dietary source for clients needing high-protein intake postoperatively. It may be included in a balanced diet but should not be relied upon for protein needs.

Choice B rationale

Bananas are primarily composed of carbohydrates and potassium, with negligible protein content. They are beneficial for energy and electrolyte balance but do not serve as a high-protein food source.

Choice C rationale

Avocado is rich in healthy fats and provides some protein, but its protein content is lower than that of legumes. It is ideal for supporting general nutrition but not for maximizing protein intake.

Choice D rationale

Black beans are a high-protein legume and an excellent source for vegetarians. They contain significant amounts of essential amino acids, making them suitable for clients needing to enhance protein intake during postoperative recovery.

Choice A rationale

Remaining flat in bed post-thoracentesis can impair respiratory function by reducing lung expansion. Proper positioning facilitates pleural fluid clearance and reduces dyspnea risk. Elevating the head enhances ventilation and drainage, improving post-procedural recovery and minimizing complications.

Choice B rationale

Post-procedure chest x-rays confirm successful fluid removal and monitor for complications like pneumothorax, common after pleural interventions. Imaging validates lung re-expansion and ensures pleural integrity, critical for addressing new or worsening respiratory distress symptoms.

Choice C rationale

Aseptic, not clean technique, minimizes infection risk during thoracentesis. Sterile precautions protect against bacterial introduction into the pleural space, which can cause empyema, a severe complication. All materials and the procedure field should meet sterile standards.

Choice D rationale

Urinary catheter insertion is unrelated to thoracentesis and poses unnecessary infection risks. The procedure focuses on resolving pleural fluid issues, and urinary monitoring is not standard unless clinically indicated for other medical concerns. .