ATI learning system Respiratory Accurate 100% 2024

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretion? A. The client is unable to speak B. The client's airway secretions were last suctioned 2 hr ago C. The client coughs and expectorates a large mucous plug D. The nurse auscultate coarse crackles in the lung fields - ANSWERD. The nurse auscultates coarse crackles in the lung fields should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube and then suction the client's airway secretions - who has tracheostomy with inflated cuff in place is unable to speak - should assess the need for suctioning every 2 hr and then suction as necessary - should assess the client's airway after coughing and only suction client's secretions if client is not able to cough and expectorate secretions A nurse in a clinic is providing teaching for a client who is to have a tuberculin skin test. Which of the following information should the nurse include? A. If the test is positive, it means you have an active case of TB B. If the test is positive, you should have another tuberculin test in 3 weeks C. You must return to the clinic to have the test read in 2 or 3 days D. A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance - ANSWERC. You must return to the clinic to have the test read 2 or 3 days should have skin test read in 2-3 ays. Area of induration after 48-72 hr indicates exposure to the tubercle bacillus. If the client does not return to have test read within 72 hr, another tuberculin test is necessary - positive test means client has exposed TB but doesn't mean that the client has an active case of TB, should have chest x-ray to rule out active TB - Who have positive skin test should have x-ray to rule out active TB. -subsequent test will be always positive - will inject 0.1mL of purified protein derivates intradermally to dorsal aspect of the forearm A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. Apply warm compress to the face B. Take aspirin 650 mg by mouth for mild pain C. Close your mouth when sneezing D. Lie on your back with your head elevated 30 degree when resting - ANSWERD. Lie on your back with your head elevated 30 degree when resting the nurse should instruct client to rest in semi-Fowler position to prevent aspiration of nasal secretions - should apply cold compresses to his face to decrease swelling - should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation - should open her mouth when sneezing to reduce straining on the incisional site A nurse is planning for a client who has chronic pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat high-calorie food first B. Increase intake of water at meal times C. Perform active ROM exercise before meals D. Keep salitine crackers nearby for snaking - ANSWERA. Eat high-calorie foods first who has COPD experiences early satiety- should eat calorie-dense foods first - it is important to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the clients should limit intake of water at mealtimes to reduce the feeling of early satiety - Should rest before meals to decrease dyspnea before meals - should keep foods on hand for snacking, but should avoid dry and salty foods, which can place the client at risk for aspiration and make mouth dry A nurse in the ED is assessing a client for a closed pneumothorax and significant bruising of the left chest following a motor vehicle crash. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi - ANSWERA. Absence of breath sounds