A nurse is caring for a client who has a tracheostomy.
Which of the following actions should the nurse perform first when providing tracheostomy care?

Choice A rationale:

Initiate a second peripheral IV is generally done to ensure reliable access for medication or fluid administration, especially in situations where multiple interventions are required. However, based on the information provided, there is no immediate indication that a second IV is necessary. The client's symptoms are more focused on managing and monitoring the current situation rather than starting additional IV lines at this point.

Choice B rationale:

Apply oxygen is a recommended action despite the client’s oxygen saturation being 97% on room air. The presence of chest pain and anxiety could indicate that the client may benefit from supplemental oxygen to alleviate symptoms and ensure adequate oxygenation. Applying oxygen can help reduce the client's respiratory distress and improve comfort, especially when experiencing sharp chest pain and rapid, shallow breathing.

Choice C rationale:

Obtain vital signs every 5 minutes is crucial in monitoring the client’s condition closely. Given the client's symptoms of anxiety, chest pain, and abnormal respirations, frequent monitoring will help detect any changes or deterioration in the client’s status. Regular vital sign checks are essential to ensure timely intervention if the client’s condition worsens or if any new symptoms arise.

Choice D rationale:

Perform gastric lavage is not indicated based on the client's symptoms and the information provided. Gastric lavage is typically used in cases of poisoning or overdose, not for symptoms of chest pain and anxiety. Therefore, this action is not appropriate for the client's current presentation.

Choice E rationale:

Prepare to administer anticoagulants is a specific intervention often considered for conditions like suspected pulmonary embolism or myocardial infarction. However, without more information on the client’s cardiac status or specific diagnostic results indicating the need for anticoagulants, this action cannot be recommended solely based on the provided data.

Choice F rationale:

Place the client in high-Fowler’s position is beneficial for improving breathing and reducing the workload on the heart. This position helps in alleviating symptoms related to respiratory distress and can be particularly helpful for clients with chest pain and rapid, shallow respirations. It facilitates better lung expansion and improves oxygenation.

Choice C.

Choice A rationale

Keeping both arms below the heart level can actually increase the risk of lymphedema development. This position can lead to pooling of lymphatic fluid in the arm, which can exacerbate swelling.

Choice B rationale

Avoiding range-of-motion exercises with the affected arm is not recommended. Regular gentle exercises can help promote lymphatic drainage and prevent lymphedema.

Choice C rationale

Using the client’s left arm (the non-operated arm) to draw blood samples is a recommended practice. This reduces the risk of infection and injury to the right arm, which could potentially trigger or worsen lymphedema.

Choice D rationale

Obtaining blood pressure readings using the client’s right arm (the operated arm) is not recommended. The pressure exerted by the blood pressure cuff can obstruct lymphatic flow and contribute to lymphedema.