what is the best nursing intervention for a patient experiencing respiratory distress
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

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

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation. Oxygen therapy is the initial and priority intervention to ensure an adequate oxygen supply to the body tissues. Administering bronchodilators (Choice B) may be appropriate for specific respiratory conditions like asthma or COPD but is not the first-line intervention in all cases of respiratory distress. Administering IV fluids (Choice C) is not a standard intervention for respiratory distress unless there is an underlying cause like dehydration. Repositioning the patient (Choice D) can aid in optimizing ventilation but is not the primary intervention for respiratory distress.

2. What is the priority nursing action for a patient with shortness of breath?

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

3. A nurse is providing teaching to a client who has a new prescription for albuterol. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because albuterol is used to treat shortness of breath during an asthma attack. Choice A is incorrect as albuterol is a rescue medication used during an asthma attack, not for prevention. Choice C is incorrect as albuterol should not be taken with daily vitamins. Choice D is incorrect as albuterol is not typically taken at bedtime for asthma prevention.

4. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

5. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

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