A nurse is planning to perform tracheostomy care for a toddler.
which of the following is an appropriate action for nurse to take?

The correct answer is choiced. Encourage the adolescent to perform incentive spirometry to maintain lung capacity.

Choice A rationale: Avoiding influenza and pneumococcal vaccines for 24 months is not recommended. Vaccinations are crucial for preventing respiratory infections, which can be particularly dangerous for individuals with muscular dystrophy due to their compromised respiratory function.

Choice B rationale: Initiating a referral for chest physiotherapy every 4 hours is excessive and impractical. While chest physiotherapy can be beneficial, it is typically recommended at a frequency that is manageable and tailored to the individual’s needs.

Choice C rationale: Recommending the adolescent use a wheelchair to prevent stress on the lower extremities is not ideal. Encouraging mobility and physical activity as tolerated is important to maintain muscle strength and function for as long as possible.

Choice D rationale: Encouraging the adolescent to perform incentive spirometry to maintain lung capacity is appropriate. Incentive spirometry helps improve lung function and prevent respiratory complications, which are common in individuals with muscular dystrophy.

Choice A rationale

Increased urine output is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.

Choice B rationale

Increased expectoration, or coughing up and spitting out mucus, is a sign that chest physiotherapy is effective. The goal of chest physiotherapy is to help clear the thick, sticky mucus from the lungs of children with cystic fibrosis.

Reduced pain is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.

Choice D rationale

An increased heart rate is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.