what is the priority nursing action for a patient with shortness of breath
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. 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.

2. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. An elevated temperature of 38.2°C (100.8°F) indicates a potential infection and should be reported to the provider. Elevated temperature postoperatively is often a sign of infection or inflammation, which can delay healing and increase the risk of complications. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate an immediate need for reporting to the provider. Serous drainage at the incision site is expected in the initial postoperative period as part of the normal healing process, a heart rate of 92/min can be a normal response to surgery due to stress or pain, and a blood pressure of 130/80 mm Hg is also within normal limits for most clients.

3. Which medication is used to treat opioid overdose?

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the standard medication for reversing opioid overdose by blocking opioid receptors. Choice B, Epinephrine, is used to treat severe allergic reactions (anaphylaxis) and cardiac arrest, not opioid overdose. Choice C, Lidocaine, is a local anesthetic used for numbing purposes and managing certain types of arrhythmias, not for opioid overdose. Choice D, Atropine, is used to treat bradycardia, organophosphate poisoning, and nerve agent toxicity, not opioid overdose.

4. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

5. 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.

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