A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

A. Encouraging the patient to increase oral fluid intake may help with secretion thinning over time, but in the immediate situation of thick respiratory secretions, it will not provide immediate relief.
B. Applying humidification to the oxygen would be helpful over time to thin secretions, but it is not the immediate action needed to address the difficulty in clearing thick secretions.
C. Suctioning the tracheostomy is the priority action in this situation. When a patient with a tracheostomy has difficulty clearing thick secretions, suctioning is the most effective way to relieve the obstruction and improve airflow, thereby addressing the immediate respiratory distress.
D. Offering reassurance is important, but it does not address the patient’s immediate need to clear the airway. Managing the respiratory distress should take priority.

A. The client is likely experiencing an allergic reaction to penicillin, such as anaphylaxis, which can cause symptoms like itching, dizziness, and difficulty breathing. The first step is to stop the infusion immediately to prevent further exposure to the allergen.
B. Elevating the head of the bed might be helpful if the client is experiencing respiratory distress, but stopping the infusion is the priority action.
C. Auscultating the client's breath sounds may be useful later to assess the severity of respiratory distress, but it is not the first action in an acute allergic reaction.
D. Calling the provider is important, but the immediate priority is stopping the infusion to prevent further harm from the allergic reaction.