a nurse is developing a plan of care for a client who is postoperative which of the following interventions should the nurse include in the plan to pr
Logo

Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?

Correct answer: C

Rationale: Encouraging the use of an incentive spirometer is vital in preventing pulmonary complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, promoting lung expansion, and preventing atelectasis. Range-of-motion exercises help prevent musculoskeletal complications, while placing suction equipment at the bedside is important but not directly related to preventing pulmonary complications. Administering an expectorant may help with clearing secretions but is not as effective in preventing postoperative pulmonary complications as using an incentive spirometer.

2. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

Correct answer: A

Rationale: The most important action a client can take to protect against errors is to bring a list of all medications and their purposes. This helps ensure that the healthcare team has accurate information about the client's medications, reducing the risk of medication errors, which are the most common type of healthcare mistake. Knowing the medications and their purposes can also aid in preventing drug interactions and adverse effects during the surgical procedure.

3. After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?

Correct answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

4. A client is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select ONE that does not apply)

Correct answer: D

Rationale: When educating a client on smoking cessation, the nurse should include several strategies. Finding an activity to keep hands busy helps distract from smoking urges. Making a list of reasons to quit smoking reinforces motivation. Identifying a consequence for backsliding can serve as a deterrent. Drinking water is beneficial for overall health but is not directly related to smoking cessation. It's crucial to support the client, encourage healthy habits, and address challenges without punitive measures.

5. A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?

Correct answer: C

Rationale: Pursed-lip breathing is a common manifestation in clients with emphysema. It helps to increase the duration of exhalation and reduce air trapping, aiding in the management of the condition. Decreased chest expansion and bradypnea are not typically associated with emphysema. While cyanosis can occur in severe cases, pursed-lip breathing is a more specific and commonly observed sign of emphysema.

Similar Questions

A client with tuberculosis (TB) is taking isoniazid (INH). Which instruction is most important for the nurse to include?
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
While assessing a client with a tracheostomy, a nurse notes that the tracheostomy tube is pulsing with the heartbeat during a pulse check. No other abnormal findings are noted. What action should the nurse take?
A client is receiving oxygen therapy via nasal cannula. Which finding indicates that the therapy is effective?
What question should a nurse ask a client who has an anteroposterior (AP) chest diameter equal to the lateral chest diameter?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses