a patient is admitted with suspected pneumonia what is the nurses priority assessment
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A patient is admitted with suspected pneumonia. What is the nurse's priority assessment?

Correct answer: B

Rationale: The correct answer is to assess the patient's oxygen saturation. In suspected pneumonia, ensuring adequate oxygenation is critical to monitor respiratory function. Auscultating lung sounds is important but assessing oxygen saturation takes precedence as it directly reflects the patient's oxygen levels. Monitoring white blood cell count is more related to infection assessment rather than immediate respiratory status. Checking skin integrity is essential for overall patient care but is not the priority in a patient with suspected pneumonia.

2. A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?

Correct answer: B

Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.

3. When a nurse is assigned to float to another unit and feels unprepared, what is the most appropriate course of action?

Correct answer: B

Rationale: When a nurse is assigned to float to another unit and feels unprepared, the most appropriate course of action is to request help and clarification from the charge nurse. This allows the nurse to address any concerns, seek guidance, and ensure safe patient care. Refusing the assignment (Choice A) is not a constructive approach as it may leave the unit short-staffed and compromise patient safety. Completing the assignment and documenting concerns later (Choice C) is not recommended as it delays addressing the issues at hand. Filing a formal complaint with hospital administration (Choice D) should be considered only after attempting to resolve the issue at the unit level first.

4. A patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?

Correct answer: A

Rationale: The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.

5. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?

Correct answer: B

Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.

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