(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 A rationale:

Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.

Choice B rationale:

Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.

Choice C rationale:

Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.

Choice D rationale:

This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.

Choice A rationale:

Increasing the flow rate of oxygen may not be the priority action because the patient's shortness of breath could be due to a problem with the mask itself, rather than the amount of oxygen being delivered. Before making any adjustments to the oxygen flow rate, it is essential to assess the equipment's integrity.

Choice B rationale:

This is the priority action because a partial rebreather mask relies on the patient's exhaled breath to partially fill the reservoir bag. If the mask bag does not remain inflated during both inspiration and expiration, the patient may not be receiving the appropriate oxygen concentration, leading to increased shortness of breath. Checking the mask bag ensures that the mask is functioning correctly and delivering the intended oxygen concentration.

Choice C rationale:

Switching the patient to a non-rebreather mask for higher oxygen delivery is not the priority action in this scenario. The non-rebreather mask is used when high oxygen concentrations are required, such as in emergencies or when a patient's condition requires immediate intervention. However, the priority at this moment is to assess the current equipment's effectiveness before considering a change in oxygen delivery method.

Choice D rationale:

Reassuring the patient that shortness of breath is common with this type of mask is not appropriate without first addressing the issue at hand. The nurse should first assess the mask's functionality to ensure it is working correctly and providing the appropriate oxygen concentration before addressing the patient's concerns.