a nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube which of the following instructions sho
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Nursing Elites

ATI RN

Medical Surgical ATI Proctored Exam

1. A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

Correct answer: C

Rationale: It is essential to advise the client to avoid speaking for extended periods after the removal of the endotracheal tube to prevent strain on the vocal cords and allow the airway to recover. Speaking for prolonged periods can lead to irritation and potentially affect the healing process. The other options are also important post-extubation instructions, such as using the incentive spirometer to maintain lung function, positioning in a side-lying position for comfort, and frequent monitoring of vital signs to ensure the client's stability.

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 tests positive for alpha1-antitrypsin (AAT) deficiency and asks the nurse, What does this mean? How should the nurse respond?

Correct answer: C

Rationale: Alpha1-antitrypsin (AAT) deficiency is associated with a higher risk of chronic obstructive pulmonary disease (COPD), especially if the individual smokes. This condition is caused by a recessive gene. Individuals with one allele typically produce enough AAT to prevent COPD unless they smoke. However, those with two alleles are at high risk for COPD even without exposure to smoke or other irritants. Being a carrier of AAT deficiency does not guarantee that one's children will develop the disease; it depends on the AAT levels of the partner. While involving a genetic counselor may be beneficial in the long run, the immediate concern of the client's question should be addressed first.

4. A client who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?

Correct answer: D

Rationale: During a bronchoscopy with a rigid scope and general anesthesia, the provider will typically place the client's neck in a hyperextended position to allow better visualization and access to the airways. This position helps to align the trachea for easier insertion of the scope.

5. A client is vomiting. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: When a client is vomiting, the priority action for the nurse is to prevent the client from aspirating. Aspiration can lead to serious respiratory complications. Providing the client with an emesis basin can be helpful but preventing aspiration takes precedence. Notifying housekeeping and administering an antiemetic are secondary actions that can be addressed once the client's safety is ensured.

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