what is the most important nursing intervention for a patient experiencing an acute asthma attack
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Nursing Elites

ATI RN

ATI Exit Exam RN

1. What is the most important nursing intervention for a patient experiencing an acute asthma attack?

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. During an acute asthma attack, bronchodilators like albuterol are crucial to help dilate the airways and improve breathing. Providing supplemental oxygen (Choice B) may be necessary but is not the priority intervention. Starting IV fluids (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of care but are not the most critical interventions during an acute asthma attack.

2. A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: Placing a pillow under the client's lower legs is the correct intervention because it helps prevent pressure on the incision site and promotes circulation. Elevating the lower legs also aids in reducing swelling and improving blood flow. Applying heat to the incision site (Choice A) is contraindicated in the early postoperative period as it can increase inflammation and the risk of infection. Keeping the client's knee flexed while in bed (Choice B) may lead to contractures or limited extension of the knee joint. Placing a pillow under the client's knee (Choice C) may cause hyperextension of the knee, which is also not recommended post knee arthroplasty.

3. What is the most important nursing intervention for a patient with a suspected pulmonary embolism?

Correct answer: A

Rationale: The most important nursing intervention for a patient with a suspected pulmonary embolism is to administer anticoagulants. Anticoagulants help prevent further clot formation in the patient's blood vessels, reducing the risk of complications such as worsening of the pulmonary embolism or development of new clots. Administering oxygen (Choice B) may be necessary to support the patient's oxygenation, but anticoagulants take precedence as they target the underlying cause of the pulmonary embolism. Repositioning the patient (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of patient care but are not the primary intervention for a suspected pulmonary embolism.

4. A client is postoperative following cataract surgery. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client postoperative following cataract surgery is to avoid bending at the waist. Bending at the waist can increase intraocular pressure, which is not recommended after cataract surgery. Choices A, C, and D are incorrect because lying flat for 24 hours after surgery may not be necessary, wearing an eye patch at night for a week is not a standard postoperative instruction for cataract surgery, and sleeping on the affected side may not necessarily reduce discomfort and can increase pressure on the eye.

5. A client with asthma is prescribed a corticosteroid inhaler. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction is to rinse the mouth after each use of a corticosteroid inhaler to prevent oral candidiasis (thrush). Choice A is incorrect because corticosteroid inhalers are usually used on a regular schedule to control asthma symptoms, not just for acute symptoms. Choice C is incorrect as corticosteroid inhalers are typically used for long-term management, not just during asthma attacks. Choice D is incorrect as administering a bronchodilator after using a corticosteroid is not a standard practice and is not necessary for the effectiveness of the corticosteroid inhaler.

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