what is the best nursing intervention for a patient experiencing respiratory distress
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. What is the best intervention for a patient experiencing respiratory distress?

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation. Oxygen therapy is the initial and priority intervention to ensure an adequate oxygen supply to the body tissues. Administering bronchodilators (Choice B) may be appropriate for specific respiratory conditions like asthma or COPD but is not the first-line intervention in all cases of respiratory distress. Administering IV fluids (Choice C) is not a standard intervention for respiratory distress unless there is an underlying cause like dehydration. Repositioning the patient (Choice D) can aid in optimizing ventilation but is not the primary intervention for respiratory distress.

2. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider recommend?

Correct answer: C

Rationale: The correct answer is 'Lean beef.' Lean beef is a good source of protein, which is essential for a balanced diet. While carrots and bananas are healthy food choices, they are not specifically recommended for clients with hypertension. Whole grains are a better alternative to refined grains for individuals with hypertension, but lean beef is a more suitable recommendation due to its protein content.

3. What is the best position for a patient with respiratory distress?

Correct answer: A

Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.

4. A nurse is providing discharge instructions to a client with chronic obstructive pulmonary disease (COPD) who is prescribed home oxygen. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The correct statement for the nurse to make is to advise the client to check the oxygen equipment daily for proper function. This is crucial to ensure the client's home oxygen therapy is working effectively and safely. Choice B is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored upright, not lying flat. Choice D is incorrect and unsafe advice, as smoking near an oxygen source can lead to a fire hazard.

5. A nurse is caring for a client who has cirrhosis. Which of the following laboratory values should the nurse expect to be elevated?

Correct answer: B

Rationale: The correct answer is B: Ammonia. In clients with cirrhosis, impaired liver function can lead to elevated levels of ammonia in the blood. Elevated ammonia levels can result in hepatic encephalopathy, a condition characterized by altered mental status. Serum albumin (Choice A) is typically decreased in cirrhosis due to the liver's reduced synthetic function. Bilirubin (Choice C) levels can be elevated in liver disease but may not always be the most specific marker for cirrhosis. Prothrombin time (Choice D) is prolonged in cirrhosis due to impaired liver synthesis of clotting factors.

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