the most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023 Quizlet

1. What is the most appropriate nursing order for a patient who develops dyspnea and shortness of breath?

Correct answer: B

Rationale: Maintaining the patient in an orthopneic position as needed is the most appropriate nursing order for a patient experiencing dyspnea and shortness of breath. This position helps to optimize lung expansion, improve oxygenation, and alleviate breathing difficulties. It is a strategic intervention to enhance respiratory function in patients with respiratory distress. Choice A is incorrect because strict bed rest may not address the underlying respiratory issue effectively. Choice C is premature as administering high-flow oxygen should be based on a comprehensive assessment. Choice D is inappropriate as encouraging vigorous physical activity can exacerbate breathing problems in a patient experiencing dyspnea.

2. A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Correct answer: A

Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.

3. When caring for a client on pressure support ventilation (PSV), which statement by the nurse indicates an understanding of PSV?

Correct answer: B

Rationale: Pressure support ventilation (PSV) is a mode that delivers a preset pressure when the client initiates a breath. This support helps the client to breathe spontaneously by reducing the work of breathing. The correct statement indicating an understanding of PSV is that it allows preset pressure to be delivered during spontaneous ventilation, as it assists the client's efforts without controlling the rate or volume of each breath.

4. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

5. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

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