A nurse is caring for a patient who has a tracheostomy and is receiving oxygen therapy via tracheostomy collar at 40% FiO2. The nurse should ensure that which of the following is in place to prevent complications?

The correct answer is choice B: Diagnosis.

Choice A rationale:

Assessment is the first phase of the nursing process where the nurse collects comprehensive data pertinent to the patient’s health or the situation. In the scenario, the nurse has already gathered data about the client’s respiratory status, indicating that the assessment phase has been completed.

Choice B rationale:

Diagnosis is the phase where the nurse analyzes the assessment data to determine the issues, which in this case is ‘impaired gas exchange.’ This is the phase where the nurse identifies that the client’s symptoms (dyspnea and cyanosis) and elevated respiratory rate are indicative of impaired gas exchange.

Choice C rationale:

Planning is the phase where the nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. It follows the diagnosis and involves setting priorities, but in the given scenario, the nurse is still at the stage of identifying the problem rather than planning interventions.

Choice D rationale:

Evaluation is the final phase of the nursing process where the nurse assesses the client’s response to the nursing actions and plan’s effectiveness towards achieving the health care goals. Since the nurse is determining the issue, not evaluating the client’s response to interventions, this phase is not the correct answer.

Choice A rationale:

Although a tracheostomy collar provides oxygen directly to the trachea, the advantage specified in the question is related to the ability to breathe room air when disconnected from the oxygen source.

Choice B rationale:

This is the correct answer because a tracheostomy collar has an opening that allows the patient to breathe room air when the oxygen source is disconnected. This feature enables the patient to participate in activities without continuous oxygen delivery, promoting mobility and reducing the feeling of being tethered to an oxygen supply.

Choice C rationale:

A tracheostomy collar does not provide the highest fraction of inspired oxygen (FiO2) among low-flow systems. High-flow systems, such as non-rebreather masks or venturi masks, typically provide the highest FiO2.

Choice D rationale:

A tracheostomy collar does not deliver a fixed amount of oxygen independent of the patient's breathing pattern. Instead, it provides supplemental oxygen in response to the patient's inspiratory effort, which is a characteristic of low-flow oxygen delivery systems.