what should the nurse do first when a client with a tracheostomy exhibits respiratory distress
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What should the nurse do first when a client with a tracheostomy exhibits respiratory distress?

Correct answer: B

Rationale: The correct initial action when a client with a tracheostomy exhibits respiratory distress is to suction the tracheostomy. This helps to clear secretions and improve the client's ability to breathe. Notifying the provider (choice A) can cause a delay in immediate intervention. Administering a bronchodilator (choice C) may be necessary but is not the priority in this situation. Increasing the oxygen flow rate (choice D) can be helpful but should come after addressing the immediate need for suctioning to clear the airway.

2. How should a healthcare provider assess and manage a patient with a suspected urinary tract infection (UTI)?

Correct answer: A

Rationale: When assessing and managing a patient with a suspected UTI, the priority is to start antibiotic therapy to treat the infection. Antibiotics are crucial in eliminating the bacteria causing the UTI. While hydration is important to help flush out the bacteria, pain management can help alleviate discomfort but is not the primary treatment. Patient education is vital for prevention and management but is not the immediate intervention required for a suspected UTI.

3. What are the key differences between hypoglycemia and hyperglycemia?

Correct answer: A

Rationale: Hypoglycemia typically presents with sweating and trembling, while hyperglycemia is characterized by frequent urination and thirst. Therefore, the correct key differences between hypoglycemia and hyperglycemia are that hypoglycemia includes symptoms like sweating and trembling, while hyperglycemia involves symptoms such as frequent urination and thirst. Choices B, C, and D are incorrect because they do not accurately represent the characteristic symptoms of hypoglycemia and hyperglycemia, as stated in the question.

4. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?

Correct answer: C

Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.

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

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.

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