what is the priority nursing action for a patient with shortness of breath
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Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. What is the priority nursing action for a patient with shortness of breath?

Correct answer: A

Rationale: Administering oxygen is the priority nursing action for a patient experiencing shortness of breath. Oxygen therapy aims to improve oxygenation levels quickly, addressing the underlying cause of the symptom. Repositioning the patient, checking oxygen saturation, and elevating the head of the bed are important interventions but administering oxygen takes precedence in this scenario to ensure adequate oxygen supply to the body.

2. What is the initial action a healthcare provider should take when a patient presents with chest pain?

Correct answer: C

Rationale: The correct initial action when a patient presents with chest pain is to obtain an ECG. This helps assess the heart's electrical activity and determine the cause of chest pain. Administering aspirin or oxygen therapy may be necessary later based on the ECG findings, but obtaining an ECG is the priority to evaluate the cardiac status. Surgery preparation is not the initial action for chest pain and should only be considered after a thorough assessment.

3. What is the initial step in managing a suspected pulmonary embolism in a patient?

Correct answer: A

Rationale: Administering oxygen is the initial step in managing a suspected pulmonary embolism. Oxygen therapy is crucial to improve oxygenation levels in the blood when there is a suspected blockage in the pulmonary artery. Administering anticoagulants, although important in the treatment of pulmonary embolism, is not the first step as ensuring adequate oxygen supply takes precedence. Repositioning the patient or administering IV fluids are not the primary interventions for a suspected pulmonary embolism and are not as essential as providing oxygen support.

4. A client is 2 hours postoperative following a total knee arthroplasty. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A pain level of 8 is high and may indicate inadequate pain control or complications following surgery. Monitoring and managing pain is crucial postoperatively to ensure patient comfort and prevent complications. A heart rate of 88/min, capillary refill of 2 seconds, and a temperature of 37.8°C (100°F) are within normal ranges and do not typically require immediate reporting unless in the context of other concerning signs or symptoms.

5. 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.

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