a nurse is caring for a newborn who has respiratory distress which of the following actions should the nurse take first
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a priority intervention as it helps ensure the airway is patent and allows for effective breathing. Administering oxygen, placing the newborn in a prone position, and notifying the healthcare provider are all important actions but should come after ensuring the airway is clear. Administering oxygen may not be effective if the airway is obstructed. Placing the newborn in a prone position can worsen respiratory distress in infants. While notifying the healthcare provider is important, immediate intervention to clear the airway takes precedence in this situation.

2. A nurse is assessing a client who had a stroke and is showing signs of dysphagia. Which finding indicates this condition?

Correct answer: A

Rationale: Abnormal mouth movements are a key sign of dysphagia, a condition commonly seen in stroke clients. Dysphagia refers to difficulty swallowing, which can manifest as abnormal movements of the mouth during eating or drinking. In stroke patients, dysphagia increases the risk of aspiration, where food or liquids enter the airway instead of the esophagus, leading to potential complications such as pneumonia. Choices B, C, and D are not directly indicative of dysphagia. Inability to stand without assistance may indicate motor deficits, paralysis of the right arm suggests a neurological impairment, and loss of appetite can be a non-specific symptom in many conditions but does not specifically point to dysphagia.

3. A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?

Correct answer: C

Rationale: The healthcare provider should first assess the patient to determine if any harm has occurred as a result of the medication error. Checking the patient's condition takes precedence as it allows for immediate intervention if necessary. Notifying the provider (choice A) can come later once the patient's condition is assessed. Reporting to the risk manager (choice B) and completing an incident report (choice D) are important steps but should follow the initial assessment of the patient to ensure timely and appropriate actions are taken.

4. A nurse is providing education on the use of corticosteroids. Which of the following should be included?

Correct answer: A

Rationale: The correct answer is to monitor for signs of hyperglycemia when educating on corticosteroids. Corticosteroids can increase blood glucose levels, making it essential to watch for hyperglycemia, especially in diabetic patients. Choice B is incorrect because corticosteroids should not be abruptly stopped due to the risk of adrenal insufficiency. Choice C is incorrect as corticosteroids are associated with various adverse effects, making long-term use risky. Choice D is incorrect as dehydration is not typically a primary concern directly related to corticosteroid use.

5. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?

Correct answer: C

Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.

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