a patient with copd is admitted with shortness of breath and a productive cough which of the following interventions should the nurse implement first
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A patient with COPD is admitted with shortness of breath and a productive cough. Which of the following interventions should the nurse implement first?

Correct answer: C

Rationale: Placing the patient in a high-Fowler’s position should be implemented first. This intervention helps improve lung expansion, making it easier for the patient to breathe. Elevating the head of the bed reduces the work of breathing and can alleviate symptoms of respiratory distress. Administering oxygen, encouraging coughing and deep breathing, and administering a bronchodilator are important interventions in the care of a patient with COPD, but positioning the patient for optimal lung expansion takes precedence in this scenario.

2. What is a recommended nursing action for a client who experiences short-term memory loss after Electroconvulsive Therapy (ECT)?

Correct answer: B

Rationale: The correct nursing action for a client experiencing short-term memory loss after ECT is to offer frequent orientation and reassurance. This helps the client feel supported and aids in memory retention. Providing cognitive-behavioral therapy (Choice A) may be beneficial for other conditions but is not the primary intervention for memory loss post-ECT. Administering a sedative (Choice C) is not recommended as it may further affect memory recall. Referring the client to a neurologist (Choice D) for further evaluation is not the initial action needed; offering support and orientation should be the first approach to manage memory issues post-ECT.

3. A nurse is reviewing the medication orders for a client with heart failure. Which of the following medications should the nurse clarify with the provider?

Correct answer: D

Rationale: The correct answer is D, Ibuprofen. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen heart failure due to its effects on renal function and fluid retention. Therefore, the nurse should clarify the use of Ibuprofen with the provider. Choices A, B, and C (Furosemide, Spironolactone, and Digoxin) are commonly prescribed medications for heart failure that help manage symptoms and improve cardiac function, so they do not need clarification in this scenario.

4. If a nurse is uncomfortable documenting a verbal prescription, what should the nurse do?

Correct answer: B

Rationale: When a nurse is uncomfortable documenting a verbal prescription, the best course of action is to clarify the prescription with the healthcare provider. This is crucial to ensure that the information is accurate and to provide safe and appropriate care. Option A is incorrect because blindly documenting without seeking clarification can lead to errors. Option C is incorrect as refusing to document the prescription altogether is not in the best interest of the patient. Option D is also incorrect as speaking with the client's family is not the appropriate step to clarify a verbal prescription; the healthcare provider should be the primary source for this clarification.

5. Which of the following is an example of professional negligence?

Correct answer: A

Rationale: Professional negligence involves failing to meet the standard of care expected in a particular profession, which can lead to harm. In this case, not following facility guidelines can result in lapses in safety or quality of care, potentially causing harm to clients. Choices B, C, and D all represent essential aspects of professional conduct and do not directly relate to negligence.

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