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

ATI RN

ATI RN Comprehensive Exit Exam 2023

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

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

2. What is the most important nursing assessment post-surgery?

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

3. A client with a new diagnosis of type 2 diabetes mellitus is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D. Clients with diabetes should eat a snack if their blood glucose level is below 70 mg/dL, not 200 mg/dL. Option A is incorrect because checking blood glucose levels once a week may not provide adequate monitoring for someone with diabetes. Option B is incorrect as a strict limit of 50 grams of carbohydrates per day may not be suitable for everyone and can vary based on individual needs. Option C is incorrect as it is important for clients with diabetes to have a balanced diet that includes protein in moderation.

4. How should a healthcare professional assess for infection in a patient post-surgery?

Correct answer: A

Rationale: When assessing for infection in a patient post-surgery, checking the surgical site is crucial. Changes in the appearance of the surgical site, such as redness, swelling, warmth, or drainage, can indicate an infection. While checking for fever (Choice B) is also important as it can be a sign of infection, it is a more general symptom and may not always be present. Checking for abnormal breath sounds (Choice C) and skin color (Choice D) are not typically direct indicators of infection in a post-surgery patient.

5. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

Correct answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

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