what is the priority nursing action for a patient with respiratory distress

ATI RN

ATI Exit Exam RN

1. What is the priority nursing action for a patient with respiratory distress?

A. Administer oxygen
B. Reposition the patient
C. Administer bronchodilators
D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

2. When teaching a client about nutritional intake, what should be included?

A. Carbohydrates should be at least 45% of your caloric intake.
B. Protein should be at least 55% of your caloric intake.
C. Carbohydrates should be at least 30% of your caloric intake.
D. Protein should be at least 60% of your caloric intake.

Correct answer: A

Rationale: When educating a client about nutritional intake, it is important to mention that carbohydrates should constitute at least 45% of their daily caloric intake for a balanced diet. This macronutrient provides energy and is essential for proper bodily functions. Choice B is incorrect because protein should typically account for around 10-35% of total caloric intake, not 55%. Choice C is too low for the recommended carbohydrate intake, as it should be higher at 45%. Choice D is incorrect as protein intake should generally be around 10-35% of total caloric intake, not 60%.

3. A nurse is caring for a client who is 1 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take?

A. Irrigate the catheter with 0.9% sodium chloride.
B. Reposition the catheter.
C. Notify the provider.
D. Increase the rate of the continuous bladder irrigation.

Correct answer: A

Rationale: In this situation, the nurse should irrigate the catheter with 0.9% sodium chloride to help relieve any obstruction and ensure proper urinary drainage following a TURP. Repositioning the catheter may not address the underlying issue of obstruction. Notifying the provider should be done after attempting to resolve the drainage issue. Increasing the rate of continuous bladder irrigation is not the initial intervention for a catheter that is not draining.

4. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?

A. Blood pressure 140/90 mm Hg
B. Heart rate of 88/min
C. LDL cholesterol 110 mg/dL
D. Respiratory rate of 16/min

Correct answer: D

Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.

5. Nurses caring for four clients. Which of the following client data should the nurse report to the provider?

A. A client who has pleurisy and reports pain of 6 on a scale of 0 to 10 when coughing
B. Client drained a total of 110 mL of serosanguineous fluid from the Jackson Pratt drain within the first 24 hours following surgery
C. Client who is 4 hours postoperative and has a heart rate of 98 per minute
D. The client has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

Correct answer: D

Rationale: The correct answer is D. The client with chemotherapy and a low neutrophil count is at risk for infection and requires prompt intervention. Reporting this information to the provider is crucial to ensure appropriate monitoring and management to prevent potential complications. Choices A, B, and C do not indicate an immediate risk that requires immediate provider notification. A client reporting pain with pleurisy, a client draining fluid post-surgery, or a client with a heart rate of 98 per minute postoperative are not urgent enough to warrant immediate reporting compared to the client at risk for infection.