A nurse is preparing to provide tracheostomy care for a client.

Which of the following actions should the nurse plan to take?

Choice A Reason:

Suggesting that the client assist with meal planning may be appropriate, but it's not the first priority. Monitoring the client's eating behaviors and safety during meals takes precedence.

Choice B Reason:

Observe the client during and after meals. When caring for a client with bulimia nervosa, the initial priority is to monitor the client during and after meals to assess their eating behaviors and the potential for purging or other disordered eating habits. This helps ensure the client's safety and can provide valuable information for the treatment team. Once immediate safety concerns are addressed, the nurse can proceed with other aspects of care, such as assisting with meal planning, providing education on coping strategies, and referring the client to support groups as appropriate.

Choice C Reason:

Instructing the client about effective coping strategies is an important part of the treatment plan, but it's not the immediate priority. Ensuring the client's safety during meals is more critical initially.

Choice D Reason:

Referring the client to a support group can be a valuable part of long-term treatment, but it's not the first step. Monitoring and addressing immediate eating behaviors and safety come first.

Choice A Reason:

Documenting the infiltration is important for the client's medical record, but it should not be the first action when infiltration is suspected.

Choice B Reason:

Elevating the arm can help reduce swelling, but it should come after stopping the infusion.

Choice C Reason:

Applying a warm compress can help with comfort and may be done after stopping the infusion, but it is not the first action.

Choice D Reason:

Stop the infusion is correct. When a nurse observes signs of infiltration around an IV insertion site, such as edema and coolness of the skin, the first and most important action is to stop the infusion immediately. Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of going into the vein. Stopping the infusion prevents further damage to the surrounding tissue and minimizes the risk of complications.