what is the most important assessment for a patient with respiratory distress
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Nursing Elites

ATI RN

ATI RN Exit Exam Test Bank

1. What is the most important assessment for a patient with respiratory distress?

Correct answer: A

Rationale: Monitoring oxygen saturation is crucial in assessing a patient with respiratory distress because it helps determine if the patient is receiving adequate oxygen. Oxygen saturation levels provide immediate feedback on the efficiency of oxygen delivery to the tissues. Checking for abnormal breath sounds (Choice B) is relevant in respiratory assessments, but it is secondary to assessing oxygen saturation. Pitting edema (Choice C) and performing a neurological exam (Choice D) are not directly related to assessing respiratory distress and are not the primary focus when managing a patient with breathing difficulties.

2. A nurse is preparing to administer vancomycin IV to a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action the nurse should take is to administer the medication over 60 minutes. This is important because administering vancomycin over 60 minutes helps prevent red man syndrome, a reaction that can occur with rapid infusion. Monitoring the client's blood glucose level (Choice B) is unrelated to vancomycin administration. Infusing the medication rapidly (Choice C) is incorrect and can lead to adverse reactions. Administering the medication using a filter needle (Choice D) is unnecessary for vancomycin administration.

3. How should pain be assessed in a non-verbal patient?

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

4. A client has a new prescription for furosemide. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods when taking furosemide. Furosemide is a loop diuretic that can cause potassium loss, so consuming potassium-rich foods like bananas and oranges can help maintain adequate potassium levels. Choice A is incorrect because there is no need to avoid consuming dairy products. Choice C is incorrect because while fluid intake may need to be monitored, the general instruction is not to limit fluids to prevent dehydration. Choice D is incorrect because furosemide is usually best taken during the day to avoid disrupting sleep with frequent urination.

5. What is the best position for a patient experiencing shortness of breath?

Correct answer: B

Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.

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