what is the priority nursing action for a patient experiencing an acute asthma attack
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. What is the priority nursing action for a patient experiencing an acute asthma attack?

Correct answer: A

Rationale: The correct answer is to administer bronchodilators as the priority nursing action for a patient experiencing an acute asthma attack. Bronchodilators help open the airways and improve airflow, which is crucial in managing the acute respiratory distress in asthma. Corticosteroids may be used subsequently to reduce inflammation, but in the acute phase, bronchodilators take precedence. Providing supplemental oxygen is important but may not address the underlying bronchoconstriction characteristic of an asthma attack. Starting IV fluids is not a priority in managing an acute asthma attack unless indicated for specific reasons such as dehydration.

2. How should fluid balance be assessed in a patient receiving diuretics?

Correct answer: A

Rationale: Corrected Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.

3. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: Placing the client's left arm on a pillow while they are sitting helps prevent shoulder displacement and provides support for the limb post-stroke. This positioning is important to maintain proper alignment and prevent complications. Choices A, B, and C are incorrect because placing food on the left side of the mouth, providing total assistance with ADLs, and maintaining the client on bed rest do not directly address the specific needs related to unilateral paralysis and dysphagia post right hemispheric stroke.

4. A nurse is preparing to administer an IV medication to a client who has an allergy to latex. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This is crucial as it prevents direct contact of the medication with latex, reducing the risk of an allergic reaction. Choice A is incorrect as using latex gloves can still expose the client to latex. Choice B is not the best option since the administration route is not specified, and using a latex-free syringe alone may not be sufficient to prevent exposure. Choice D is not the most appropriate because the IV tubing and ports should also be latex-free to ensure complete avoidance of latex contact.

5. 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 instruct the client to avoid?

Correct answer: C

Rationale: The correct answer is C. Bacon is high in sodium, which can elevate blood pressure levels. Clients with hypertension should avoid high-sodium foods like bacon to help manage their blood pressure. Choices A, B, and D are healthier options compared to bacon and can be included in a balanced diet for someone with hypertension. Bananas are a good source of potassium, which can help in managing blood pressure. Carrots are low in sodium and high in fiber, making them a heart-healthy choice. Chicken breast is a lean protein option that is beneficial for individuals with hypertension.

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