(Select all that apply): A client with a tracheostomy is being weaned from mechanical ventilation. Which of the following oxygen delivery devices can be used for this client?

Choice D rationale:

The nurse should connect the nasal cannula to a humidifier first. Dry and irritated nares are common side effects of oxygen therapy via nasal cannula, and using a humidifier adds moisture to the oxygen, reducing irritation and discomfort for the patient.

Choice A rationale:

Applying petroleum jelly to the nares is not the first action to take. It might provide temporary relief, but it is essential to address the root cause of dryness, which is the lack of moisture in the oxygen delivered.

Choice B rationale:

Increasing the flow rate of oxygen is not the first step because it may not address the dryness issue. It can lead to a higher concentration of oxygen, but it won't solve the problem of dry and irritated nares.

Choice C rationale:

Changing the nasal cannula to a face mask is not necessary to address the dryness. Face masks may not be well-tolerated by some patients, and it's better to try less invasive interventions first.

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.