A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority?
a. Delegate oral care every 4 hours.
b. Monitor and record the client's intake.
c. Place the client in a high-Fowler's position.
d. Remove the inner cannula for cleaning.
ANS: C
To promote airway clearance, this client should be placed in a semi- or high-Fowler's position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula.
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