Author Question: A client shares with the nurse that they have, almost reached the goal of smoking only one-half pack ... (Read 22 times)

charchew · **on:** Jul 23, 2018

A client shares with the nurse that they have, almost reached the goal of smoking only one-half pack of cigarettes a day. The best example of a nursing intervention to correct this unmet out-come is:

1. Discuss with the client the desire to comply with the ordered therapy
2. Suggest that the client use another smoking cessation tool to achieve the goal
3. Reevaluate the time frame originally decided upon for achievement of the goal
4. Suggest that the strength of the prescribed nicotine patches be increased to 21 mg

Question 2

The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the client's:

1. Respiratory rate
2. Complaint of chest pain
3. Lungs clear bilaterally on auscultation
4. Ability to perform incentive spirometry

jrpg123456 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 4
An unmet outcome reveals the client has not responded to interventions as planned. As a result, the nurse changes the plan of care by trying different therapies or changing the frequency or ap-proach of existing therapies. The best option is one that adds to the existing therapy. The remain-ing options should have been explored as a part of the goal-setting process or exercised if the current therapy proves ineffective.

Answer to Question 2

ANS: 3
Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine if airways are free of secretions. A complaint of chest pain would be a negative outcome, and it is not the focus for determining whether airways are free of secretions as written in the outcome statement. Having the ability to perform incentive spirometry does not determine whether the airways are clear or not. It is an in-tervention that may help achieve clear airways.