A nurse is caring for an adult client who has a tracheostomy on the medical-surgical unit.

Select the 3 findings that require immediate follow-up.

Choice A rationale

Following this major surgical procedure, the most critical nursing priority is ensuring that the client has a patent path for gas exchange. The removal of the larynx necessitates a permanent stoma, and any obstruction from secretions, blood, or edema can lead to rapid respiratory arrest. Constant monitoring of respiratory rate, effort, and oxygen saturation is vital. Airway management always takes precedence over other assessments in the immediate postoperative period to prevent life-threatening hypoxia or asphyxia.

Choice B rationale

While managing discomfort is a significant part of postoperative care and promotes recovery, it does not pose an immediate threat to life. Pain can increase heart rate and blood pressure, making the client restless, but it is considered secondary to the physiological need for oxygenation. The nurse should address pain through pharmacological and non-pharmacological means only after confirming that the respiratory status is stable. Pain assessment is important for holistic care but remains a lower priority.

Choice C rationale

Maintaining access for fluids and medications is necessary for hydration and the administration of antibiotics or analgesics. However, a displaced or occluded intravenous line is a circulatory issue that can be addressed after the airway is secured. While critical for long-term recovery and stability, it does not require the same level of emergent vigilance as the respiratory system. The nurse must ensure the line is patent but only after performing a thorough respiratory assessment.

Choice D rationale

Monitoring the surgical site for bleeding, hematoma formation, or signs of infection is a standard postoperative task. A tight or soiled dressing can indicate complications, but it is not as immediately life-threatening as a blocked airway. Integrity of the site is important for wound healing and preventing sepsis, but it falls under the category of "circulation" or "skin integrity" in the priority hierarchy. Airway patency must always be the first concern for a post-laryngectomy client.

Choice A rationale

Pursed-lip breathing is a technique that creates mild resistance to exhalation, which provides a form of positive end-expiratory pressure. This pressure keeps the smaller airways and alveoli open longer, allowing for more complete emptying of the lungs. In COPD, air trapping is a primary concern, and this maneuver helps decrease the work of breathing, improves oxygenation, and helps control the rate of respiration by prolonging the expiratory phase of the respiratory cycle.

Choice B rationale

Clients with COPD actually require a high-protein and high-calorie diet rather than a low-protein one. The work of breathing in these patients is significantly increased, leading to higher metabolic demands and energy expenditure. Malnutrition is common in advanced COPD and can lead to muscle wasting, including the respiratory muscles. Protein is essential for tissue repair and maintaining the strength of the diaphragm and intercostal muscles, which are vital for effective ventilation and overall physical function.

Choice C rationale

Restricting fluid intake is contraindicated for patients with COPD unless they have a co-existing condition like heart failure. Adequate hydration, typically 2 L to 3 L per day, is necessary to thin thick pulmonary secretions. When mucus is thin, it is much easier for the client to expectorate through coughing, which helps maintain airway patency and reduces the risk of secondary infections like pneumonia. Normal fluid intake recommendations usually range from 2000 mL to 3000 mL daily.

Choice D rationale

Scheduling exercise in the early morning is often inappropriate for COPD patients. Many of these individuals experience increased mucus accumulation overnight, leading to more significant dyspnea and productive coughing upon awakening. It is generally better to schedule activities for later in the day when the patient has had time to clear their airways and their energy levels are higher. Physical activity should be balanced with rest periods to prevent excessive fatigue and maintain functional independence.