a nurse is planning care for a client who has pneumonia which of the following interventions should the nurse include to promote airway clearance
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

2. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C: Red-tinged urine with numerous clots. This finding should be reported because it indicates excessive bleeding following a TURP procedure. Passing small clots in the urine (choice A) is expected post-TURP. Continuous bladder irrigation (choice B) is a standard procedure after TURP to prevent clot retention. Urine output of 50 mL/hr (choice D) is within the expected range postoperatively and does not indicate a complication.

3. A client who has a prescription for insulin glargine is talking to a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because insulin glargine should be stored in the refrigerator after opening to maintain its potency. Choice A is incorrect as insulin glargine should not be mixed with other insulins. Choice C is incorrect because insulin glargine is typically taken once a day. Choice D is incorrect because insulin glargine is usually taken regardless of blood glucose levels.

4. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D because enoxaparin should be injected into the abdomen to ensure proper absorption. Choice A is incorrect as enoxaparin should not be taken with food. Choice B is incorrect as enoxaparin should be injected subcutaneously, not into the muscle. Choice C is incorrect as massaging the injection site after administering enoxaparin is not recommended.

5. A nurse is reviewing the medical record of a client who has a new prescription for insulin glargine. Which of the following should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is B. Insulin glargine has a 24-hour duration of action, making it suitable for once-daily dosing for long-term blood sugar control. Choice A is incorrect as insulin glargine is a long-acting insulin with no pronounced peak effect in its action profile. Choice C is incorrect as insulin glargine is usually given at the same time each day regardless of meals. Choice D is incorrect as there is no specific requirement to avoid eating before or after taking insulin glargine.

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