Correct Answer: A

Rationale: When a client is prescribed nicotine replacement therapy, it is crucial to emphasize that smoking while using this therapy can increase the risk of a stroke. Smoking while on nicotine replacement therapy can lead to excessive nicotine levels in the body, elevating cardiovascular risks. Therefore, the nurse should educate the client on the importance of avoiding smoking while utilizing this medication. Choices B, C, and D are not relevant to the specific teaching required for a client on nicotine replacement therapy.

Correct Answer: C

Rationale: The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.

Correct Answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

Correct Answer: D

Rationale: A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.

Correct Answer: B

Rationale: Cyanosis unresponsive to oxygen therapy suggests methemoglobinemia, an adverse effect of benzocaine spray. Methemoglobinemia can lead to death if not managed promptly. The nurse should notify the Rapid Response Team to provide immediate advanced care. Administering albuterol would not address the underlying cause of cyanosis. Assessing peripheral pulses and obtaining cultures are not the priority as they do not directly address the urgent need to manage methemoglobinemia.