A nurse in a community health clinic is caring for a client who expresses plans to quit smoking within the next 2 weeks and requests a prescription for a nicotine patch. Which of the following stages of health behavior change is the client in?

Action

Contemplation

Preparation

Precontemplation

Answer and Explanation

The Correct Answer is C

Rationale:
A. Action: The action stage involves actively implementing strategies to change behavior, such as already using nicotine replacement therapy or abstaining from smoking. Since the client has not yet started quitting but intends to soon, they are not yet in this stage.

B. Contemplation: In this stage, the individual recognizes the need for change but has not yet committed to taking concrete steps. The client requesting a prescription and setting a quit date indicates they have moved beyond contemplation and are preparing for action.

C. Preparation: The preparation stage is characterized by planning to take action within the near future, usually within the next month. The client’s decision to quit within 2 weeks and request a nicotine patch reflects commitment and readiness to initiate behavior change, fitting this stage precisely.

D. Precontemplation: During precontemplation, the individual has no intention of changing behavior and may be unaware of the risks or resistant to advice. This does not apply to the client, who has already expressed motivation and plans to quit smoking soon.

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Correct Answer is ["A","E"]

Explanation

Rationale:
A. Suction the ET to remove secretions: Secretions in the airway can increase resistance, leading to higher peak inspiratory pressures. Suctioning helps clear the obstruction, restoring normal airflow and reducing pressure within the ventilator circuit.

B. Assess the ET for a cuff leak: A cuff leak would result in decreased pressure and trigger a low-pressure alarm rather than an increased peak airway pressure. In this case, the issue relates to increased resistance or obstruction, not a loss of airway seal.

C. Verify the placement of the ET: Incorrect placement of the ET tube can cause ventilation issues, but it usually leads to decreased or absent breath sounds and oxygen desaturation rather than an increase in peak pressure.

D. Check for a disconnection in the ventilator tubing: A disconnection in the circuit causes a sudden drop in pressure, triggering a low-pressure alarm instead of a high-pressure one. Therefore, this action is not related to resolving increased peak airway pressure.

E. Check for a kink in the ventilator tubing: A kink or obstruction in the ventilator tubing increases airway resistance, causing higher peak pressures. Straightening or clearing the tubing restores normal airflow and helps resolve the high-pressure alarm effectively.

A. Monitor the IV site every 8 hours. B. Use gauze to cover the IV insertion site. C. Obtain a 24-gauge catheter. D. Insert the catheter into the foot.

Correct Answer is C

Explanation

Rationale:
A. Monitor the IV site every 8 hours: In infants, IV sites should be assessed much more frequently, typically every 1–2 hours, due to their fragile veins and higher risk of infiltration or phlebitis. Monitoring every 8 hours is insufficient for safety.

B. Use gauze to cover the IV insertion site: Transparent dressings are preferred for infants because they allow continuous visualization of the IV site for signs of infiltration, phlebitis, or infection. Gauze obscures the site and may delay detection of complications.

C. Obtain a 24-gauge catheter: A 24-gauge catheter is appropriate for peripheral IV access in infants. It is small enough to fit delicate veins while allowing adequate fluid and medication administration safely.

D. Insert the catheter into the foot: Foot veins are generally avoided in infants due to higher risk of complications and limited accessibility. Preferred sites include veins on the hands, forearms, or scalp, which are safer and easier to monitor.

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A nurse in a community health clinic is caring for a client who expresses plans to quit smoking within the next 2 weeks and requests a prescription for a nicotine patch. Which of the following stages of health behavior change is the client in?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is preparing to insert a peripheral intravenous line on an infant. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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