a nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome fes following a fracture which of the following laborato
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Nursing Elites

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ATI Detailed Answer Key Medical Surgical

1. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

Correct answer: A

Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.

2. When interviewing a client recently diagnosed with lung cancer and having a 60-pack-year smoking history, what is the most important action for the nurse to take?

Correct answer: C

Rationale: Maintaining a nonjudgmental attitude during the interview is crucial to create a safe environment where the client feels comfortable and open about disclosing their smoking history and other relevant information. This approach helps establish trust and facilitates an honest conversation which is essential for providing appropriate care and support to the client.

3. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

4. A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Using the peak flow meter every morning is crucial for monitoring asthma control and making timely treatment adjustments. While using the meter when feeling short of breath or before using an inhaler can also be beneficial, the daily morning routine helps in consistent management of asthma symptoms.

5. 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.

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