A nurse is caring for a one-day postoperative client. Which of the following would be the priority for the nurse?

Choice A reason: Reducing anxiety about tracheostomy self-care aids long-term adjustment but is not the immediate priority. A new tracheostomy requires vigilant monitoring for complications like infection or skin breakdown at the stoma, which can lead to serious infections or tissue damage if not addressed promptly.

Choice B reason: Reassuring the client that the tracheostomy is temporary may provide emotional support but is not the priority. Many tracheostomies are permanent, and assuming temporariness may mislead. Immediate care focuses on preventing complications like stoma infections, making skin assessment more critical than reassurance.

Choice C reason: Frequent assessment of the skin around the tracheostomy stoma prevents complications like infection, pressure ulcers, or tissue necrosis. The stoma is prone to irritation from secretions and tube movement, which can foster bacterial growth and skin breakdown, necessitating vigilant monitoring to ensure healing and prevent serious infections.

Choice D reason: Referring to a support group aids long-term coping but is not the immediate priority. A new tracheostomy requires focus on preventing physical complications like infection or skin breakdown at the stoma, which pose immediate risks, making skin assessment more urgent than psychosocial support.

Choice A reason: Blood pressure of 94/62 mm Hg indicates hypotension, possibly from hypovolemia or anesthesia, but is less life-threatening than hypoxia. Oxygen saturation of 82% risks organ damage, making blood pressure secondary, requiring fluid or vasopressor support after addressing hypoxia.

Choice B reason: Heart rate of 110 beats/minute (tachycardia) suggests compensation for hypovolemia or pain but is less critical than oxygen saturation of 82%. Hypoxia risks rapid organ damage, while tachycardia is addressed after oxygenation, making it a lower priority in postoperative assessment.

Choice C reason: Oxygen saturation of 82% indicates severe hypoxia, risking brain and organ damage within minutes. Postoperative clients are prone to atelectasis or pulmonary edema, impairing gas exchange. Immediate oxygen therapy or airway management is critical, making this the most urgent finding.

Choice D reason: Urine output of 50 mL/hr is normal (0.5–1 mL/kg/hr), indicating adequate renal perfusion. Unlike oxygen saturation of 82%, which signals critical hypoxia, normal urine output does not require immediate attention, reflecting stable hydration and kidney function.