what is the best nursing action for a patient presenting with respiratory distress
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Nursing Elites

ATI RN

ATI RN Exit Exam

1. What is the best intervention for a patient presenting with respiratory distress?

Correct answer: A

Rationale: Administering oxygen is the most critical intervention for a patient in respiratory distress as it helps improve oxygenation levels. Oxygen therapy aims to increase oxygen saturation in the blood, providing relief and support during episodes of respiratory distress. Administering bronchodilators may be beneficial in some cases, but oxygen therapy takes precedence in addressing the underlying issue of inadequate oxygenation. Repositioning the patient may help optimize ventilation but does not directly address the primary need for increased oxygen. Providing humidified air can offer comfort but does not address the urgent need for improved oxygen levels in a patient experiencing respiratory distress.

2. What is the most important nursing action when a patient has a central line?

Correct answer: A

Rationale: The most important nursing action when a patient has a central line is to monitor for infection. Central line-associated bloodstream infections are a serious complication that can lead to severe outcomes. Monitoring for infection involves assessing the patient for signs and symptoms such as fever, chills, and hypotension. While monitoring the central line dressing, redness, and swelling are also important aspects of care, they are secondary to monitoring for infection as the primary focus should be on preventing serious complications.

3. A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.

4. A client with a pulmonary embolism is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: Administering anticoagulants as prescribed is a crucial intervention for clients with pulmonary embolism to prevent further clot formation. Encouraging the client to ambulate frequently may dislodge the clot and lead to worsening symptoms. Placing the client in a prone position can compromise respiratory function. Initiating seizure precautions is not directly related to the management of pulmonary embolism.

5. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following foods should the nurse instruct the client to avoid?

Correct answer: C

Rationale: Bananas are high in potassium, which should be avoided by clients with chronic kidney disease to prevent hyperkalemia. Apples, white bread, and grapes do not have high potassium levels and are generally acceptable for clients with chronic kidney disease unless they have other specific dietary restrictions.

Similar Questions

A nurse is assessing a client who has a history of gastroesophageal reflux disease (GERD). Which of the following findings should the nurse identify as a complication of GERD?
A nurse is providing dietary teaching to a client who has a new diagnosis of hypertension. Which of the following foods should the nurse instruct the client to avoid?
A nurse is caring for a client who has chronic kidney disease and a serum potassium level of 6.0 mEq/L. Which of the following findings should the nurse expect?
A nurse is preparing to administer insulin glargine to a client who has diabetes mellitus. Which of the following actions should the nurse take?
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

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