a patient with a history of asthma is admitted with shortness of breath what is the nurses priority intervention
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?

Correct answer: A

Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.

2. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

3. When a nurse is assigned to float to another unit and feels unprepared, what is the most appropriate course of action?

Correct answer: B

Rationale: When a nurse is assigned to float to another unit and feels unprepared, the most appropriate course of action is to request help and clarification from the charge nurse. This allows the nurse to address any concerns, seek guidance, and ensure safe patient care. Refusing the assignment (Choice A) is not a constructive approach as it may leave the unit short-staffed and compromise patient safety. Completing the assignment and documenting concerns later (Choice C) is not recommended as it delays addressing the issues at hand. Filing a formal complaint with hospital administration (Choice D) should be considered only after attempting to resolve the issue at the unit level first.

4. What are the common side effects of opioid analgesics, and how should they be managed?

Correct answer: A

Rationale: The correct answer is A. Common side effects of opioid analgesics include drowsiness and dizziness. These side effects can impair a person's ability to operate machinery or drive safely. To manage these side effects, it is essential to advise patients to avoid activities that require alertness until they know how the medication affects them. Choices B, C, and D are incorrect because respiratory depression, constipation, and nausea are also common side effects of opioids, but they are not the primary side effects being asked for in this question.

5. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

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