a patient is experiencing shortness of breath what is the nurses immediate action
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A patient is experiencing shortness of breath. What is the nurse's immediate action?

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

2. A patient with COPD is admitted with shortness of breath and a productive cough. Which of the following interventions should the nurse implement first?

Correct answer: C

Rationale: Placing the patient in a high-Fowler’s position should be implemented first. This intervention helps improve lung expansion, making it easier for the patient to breathe. Elevating the head of the bed reduces the work of breathing and can alleviate symptoms of respiratory distress. Administering oxygen, encouraging coughing and deep breathing, and administering a bronchodilator are important interventions in the care of a patient with COPD, but positioning the patient for optimal lung expansion takes precedence in this scenario.

3. A client with hypertension is receiving teaching from a healthcare provider. Which statement demonstrates comprehension of the instruction?

Correct answer: C

Rationale: Choice C is the correct answer because taking hypertension medication at the same time each day ensures its effectiveness in managing blood pressure. Consistency in medication intake is crucial to control hypertension. Option A focuses on dietary management, which is essential but not directly related to medication adherence. Option B is incorrect as stopping hypertension medication abruptly can lead to complications. Option D addresses the importance of exercise, which is beneficial for hypertension but not directly related to medication adherence.

4. What is the most important action for the nurse to take before administering digoxin to a patient?

Correct answer: A

Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.

5. A patient requires assistance to stand from a sitting position. Which action by the nurse ensures patient safety?

Correct answer: B

Rationale: The correct answer is B. Placing a gait belt around the patient for support is the safest option when assisting a patient to stand from a sitting position. This belt provides stability and support, reducing the risk of falls or injuries during the transfer. Choices A, C, and D are incorrect. Allowing the patient to pull up on the nurse's arm (Choice A) may lead to instability and compromise safety. Having the patient push off the chair with their hands (Choice C) might not provide sufficient support, especially for patients who require assistance. Asking the patient to lift themselves up without support (Choice D) can be dangerous and increase the risk of falls.

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