a nurse teaches a client who is interested in smoking cessation which statements should the nurse include in this clients teaching select all that app
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Nursing Elites

ATI RN

ATI Medical Surgical Proctored Exam 2023

1. 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.

2. A client has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Correct answer: D

Rationale: To ensure safe use of a pleural chest tube, the nurse should keep padded clamps at the bedside for use if the drainage system becomes dislodged or is interrupted. Stripping the tubing should never be done to maintain patency. Tubing junctions should be secured with tape, not clamps. Wall suction should be set at the level recommended by the device manufacturer, not the provider.

3. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?

Correct answer: B

Rationale: For clients on heparin therapy, a PTT value of 1.5 to 2.5 times the normal range is required to ensure therapeutic anticoagulation. The normal PTT range is 25 to 35 seconds. In this case, the client's PTT of 25 seconds falls below the therapeutic range, indicating that the heparin dose is insufficient. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired therapeutic effect.

4. A client is 4 hours postoperative following abdominal surgery. The client's blood pressure has dropped from 120/80 mm Hg to 90/60 mm Hg. What action should the nurse take first?

Correct answer: B

Rationale: Checking the surgical site for bleeding is crucial in this situation as it helps determine if the drop in blood pressure is due to hemorrhage, a potential postoperative complication. Identifying and addressing bleeding promptly is essential to prevent further complications and stabilize the client's condition.

5. A healthcare professional is assessing a client who has a fracture of the femur. Vital signs are obtained on admission and again in 2 hours. Which of the following changes in assessment should indicate to the healthcare professional that the client could be developing a serious complication?

Correct answer: A

Rationale: An increased respiratory rate from 18 to 44/min is a significant change that should alert the healthcare professional to a potential serious complication. Such a drastic increase in respiratory rate may indicate respiratory distress or hypoxia, which are critical conditions requiring immediate attention. The other options show minor changes in vital signs that are within normal limits and are less likely to indicate a serious complication.

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