a nurse is teaching a group of clients about emergency care for a snake bite which of the following information should the nurse include in the teachi
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Nursing Elites

ATI RN

Adult Medical Surgical ATI

1. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

2. A client has a pulmonary embolism & is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

Correct answer: C

Rationale: A large blood clot in the lungs will significantly impair gas exchange & oxygenation. Unless the clot is dissolved, this process will continue unabated.

3. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

4. A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.

5. A client is 1 day postoperative following a lobectomy with a chest tube drainage system in place. Which finding by the nurse indicates a need for intervention?

Correct answer: D

Rationale: The development of subcutaneous emphysema is a concerning finding that requires immediate intervention. Subcutaneous emphysema results from air leaking into the tissues, which can lead to respiratory compromise. It is important to address this issue promptly to prevent further complications. The other options are normal or expected findings in a chest tube drainage system. Chest tube eyelets not being visible may indicate dislodgement, continuous bubbling in the suction control chamber indicates proper functioning, and the presence of tidal fluctuation in the water seal chamber demonstrates appropriate drainage and lung re-expansion.

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