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

ATI RN

ATI RN Exit Exam Quizlet

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

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.

2. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which resource should the nurse provide?

Correct answer: B

Rationale: The correct answer is B: Food exchange lists for meal planning from the American Diabetes Association. Food exchange lists provide structured meal planning for individuals with diabetes, helping them make healthier food choices and manage their condition effectively. Choice A is incorrect because personal blogs may not provide accurate and reliable information on managing diabetes and medications. Choice C is incorrect as diabetes medication information may not be directly related to meal planning and dietary management. Choice D is incorrect because food label recommendations from the Institute of Medicine may not specifically cater to the dietary needs and meal planning guidelines recommended for individuals with diabetes.

3. A client with diabetes mellitus is being taught by a nurse about preventing long-term complications. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because checking the feet daily for open sores or wounds is crucial in preventing complications like diabetic foot ulcers. While maintaining blood glucose levels within the target range (choice A) is important in managing diabetes, it does not specifically address long-term complications. Consuming foods high in fiber (choice C) is beneficial for glycemic control but does not directly relate to preventing long-term complications. Monitoring blood pressure regularly (choice D) is important in managing diabetes but is not as directly related to preventing long-term complications as checking for foot wounds.

4. A client who is at 12 weeks of gestation and has hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory values should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D: Urine ketones present. The presence of urine ketones indicates dehydration and inadequate glucose control in clients with hyperemesis gravidarum. Reporting this finding to the provider is crucial for prompt intervention to prevent further complications. Choices A, B, and C are within normal ranges and do not directly correlate with the condition of hyperemesis gravidarum. Therefore, they are not the priority values to report in this scenario.

5. What is the most appropriate action when a patient is experiencing severe dehydration?

Correct answer: A

Rationale: The most appropriate action when a patient is experiencing severe dehydration is to administer IV fluids. This intervention is crucial in rapidly correcting dehydration and restoring fluid balance. Encouraging oral fluids may not be sufficient in cases of severe dehydration where intravenous rehydration is needed. Monitoring electrolytes is important but administering fluids takes precedence in severe dehydration. Performing a neurological exam is not the primary intervention for severe dehydration.

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