a patient with copd is admitted with shortness of breath and a productive cough which of the following interventions should the nurse implement first
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. 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.

2. A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?

Correct answer: B

Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.

3. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?

Correct answer: A

Rationale: The correct answer is A. Caring for a patient with tuberculosis requires the nurse to use an N95 respirator, gown, gloves, and eyewear to protect against airborne transmission of the disease. Choice B and D are incorrect because while communication signs for precautions are important, the essential items needed for caring for a patient with tuberculosis are personal protective equipment to prevent transmission. Choice C is also incorrect as negative-pressure airflow in the room is a facility-related requirement and not an item carried by the nurse.

4. While reviewing notes from a previous shift, a nurse finds incomplete documentation. What is the most appropriate action?

Correct answer: B

Rationale: The most appropriate action when finding incomplete documentation is to notify the nurse manager of the issue. This ensures that accurate records are maintained and the situation can be addressed properly. Completing the missing documentation on behalf of someone else may lead to inaccuracies, asking the nurse to complete it may not guarantee timely correction, and confronting the nurse could create a confrontational situation that is not conducive to effective teamwork.

5. 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.

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