what is the most important nursing intervention for a patient experiencing an acute asthma attack
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. What is the most important nursing intervention for a patient experiencing an acute asthma attack?

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. During an acute asthma attack, bronchodilators like albuterol are crucial to help dilate the airways and improve breathing. Providing supplemental oxygen (Choice B) may be necessary but is not the priority intervention. Starting IV fluids (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of care but are not the most critical interventions during an acute asthma attack.

2. A nurse is caring for a client who has a history of angina. The client reports chest pain. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take when a client with a history of angina reports chest pain is to administer sublingual nitroglycerin every 5 minutes. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain associated with angina. Aspirin is often given during a suspected heart attack, not for immediate relief of angina. Deep breathing exercises may be beneficial for anxiety or respiratory conditions but are not the first-line intervention for angina. Oxygen therapy is not the initial treatment for angina unless the client is hypoxic.

3. A nurse is reviewing the medical records of a client with chronic heart failure. What dietary recommendation should the nurse make?

Correct answer: A

Rationale: The correct answer is A: Follow a 3g sodium diet. For clients with chronic heart failure, limiting sodium intake is crucial to prevent fluid retention and exacerbation of heart failure symptoms. High sodium intake can lead to fluid buildup, causing the heart to work harder. Choices B, C, and D are incorrect. Drinking excessive fluid can worsen fluid retention in heart failure, elevating the workload of the heart. Placing the client's lower extremities on two pillows is a positioning intervention to alleviate edema, not a dietary recommendation. Maintaining oxygen saturation at 89% is more related to respiratory status rather than dietary management of chronic heart failure.

4. A client receiving intermittent enteral feedings is being cared for by a nurse. Which action should the nurse take to reduce the risk of aspiration?

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration during enteral feedings is to elevate the head of the bed to 45 degrees. This position helps prevent the reflux of feeding into the lungs. Administering the feeding over 60 minutes (Choice A) does not directly reduce the risk of aspiration. Positioning the client in a supine position (Choice B) increases the risk of aspiration as it promotes reflux. Flushing the feeding tube with water (Choice D) is important for tube patency but does not directly reduce the risk of aspiration.

5. A nurse is caring for a client who is receiving continuous enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take is to check the placement of the nasogastric tube every 8 hours. This is crucial to ensure that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Administering the feeding using a large-bore syringe (Choice A) is not recommended for enteral nutrition. Flushing the tube with water every 6 hours (Choice C) is not necessary for continuous enteral nutrition. Maintaining the client in an upright position (Choice D) is generally preferred to reduce the risk of aspiration, but it is not the most critical action compared to verifying tube placement.

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