what are the key signs of respiratory distress

ATI LPN

ATI Comprehensive Predictor PN

1. What are the key signs of respiratory distress?

A. Increased respiratory rate and use of accessory muscles
B. Decreased respiratory rate and cyanosis
C. Cyanosis and use of accessory muscles
D. Altered mental status and bradycardia

Correct answer: A

Rationale: The correct answer is A: Increased respiratory rate and use of accessory muscles are key signs of respiratory distress. When a person is experiencing respiratory distress, their respiratory rate typically increases as the body tries to compensate for the inadequate oxygenation. Additionally, the use of accessory muscles indicates that the person is working harder to breathe. Choices B, C, and D are incorrect because they do not accurately represent the key signs of respiratory distress. A decreased respiratory rate, cyanosis, altered mental status, and bradycardia are not typical signs of respiratory distress.

2. A client with diabetes is being discharged. What is an essential teaching point?

A. Monitor blood sugar levels once a week
B. Instruct the client to administer insulin before meals
C. Teach the client to exercise regularly to maintain glucose control
D. Administer oral hypoglycemics as needed

Correct answer: B

Rationale: Instructing the client to administer insulin before meals is a crucial teaching point for a client with diabetes. This action ensures proper glucose management by helping to control blood sugar levels. Monitoring blood sugar levels once a week (Choice A) may not be frequent enough to manage diabetes effectively. While regular exercise (Choice C) is beneficial for glucose control, the immediate administration of insulin is more critical at the time of discharge. Administering oral hypoglycemics as needed (Choice D) is inappropriate as it does not address the need for insulin administration for a client being discharged.

3. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

A. Aligning a trochanter wedge between the client's legs.
B. Placing a towel roll under the client's neck.
C. Applying an orthotic to the client's foot.
D. Positioning a pillow under the client's knees.

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

4. What is the proper technique for administering an intramuscular (IM) injection?

A. Locate the injection site and insert at 90 degrees
B. Insert needle at a 45-degree angle
C. Massage the site after injection
D. Insert needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering an intramuscular (IM) injection is to locate the injection site and insert the needle at a 90-degree angle. This angle ensures that the medication is delivered into the muscle for proper absorption. Choice B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Choice C is incorrect as massaging the site after an injection can cause the medication to disperse unevenly. Choice D is incorrect as a 15-degree angle would not reach the muscle layer effectively for an IM injection.

5. What advice should be given to a client experiencing constipation?

A. Encourage the client to drink water frequently
B. Increase dietary fiber to relieve constipation
C. Administer a laxative to relieve discomfort
D. Encourage the client to increase physical activity

Correct answer: B

Rationale: The correct advice to give to a client experiencing constipation is to increase dietary fiber. Dietary fiber helps relieve constipation by promoting regular bowel movements. Encouraging the client to drink water frequently (Choice A) is also important for overall bowel health, but increasing dietary fiber is more directly related to relieving constipation. Administering a laxative (Choice C) should not be the first-line recommendation and should only be considered if dietary and lifestyle changes do not work. Encouraging the client to increase physical activity (Choice D) can be beneficial for overall health but may not directly address the issue of constipation.