A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

Questions 180

ATI RN

ATI RN Test Bank

Medical Surgical Nursing Practice Questions Questions

Question 1 of 5

A healthcare provider suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the healthcare provider's priority intervention?

Correct Answer: B

Rationale: The correct answer is B: Count the respiratory rate. This is the priority intervention because anaphylaxis can lead to severe respiratory distress due to airway swelling or bronchoconstriction. Counting the respiratory rate helps to quickly assess the client's breathing status and detect any signs of respiratory distress. Inserting an IV line (choice A) may be necessary for administering medications, but assessing the respiratory rate takes precedence. Administering oxygen (choice C) is important but should follow assessing the respiratory rate. Preparing equipment for intubation (choice D) is a later intervention if respiratory distress worsens.

Question 2 of 5

During an assessment of the respiratory pattern of an older adult client receiving end-of-life care, which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Correct Answer: A

Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems. Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations. Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.

Question 3 of 5

A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?

Correct Answer: A

Rationale: The correct answer is A: Respiratory acidosis. Shallow respirations at 9/min indicate hypoventilation, leading to retention of CO2 and respiratory acidosis. This is because inadequate removal of CO2 results in an increase in carbonic acid concentration, leading to a decrease in blood pH. Respiratory alkalosis (B) is unlikely with shallow respirations. Metabolic acidosis (C) results from nonrespiratory factors. Metabolic alkalosis (D) is not related to respiratory rate.

Question 4 of 5

A client with acute respiratory distress syndrome (ARDS) requires care planning. Which of the following interventions should be included in the plan?

Correct Answer: D

Rationale: The correct answer is D, placing the client in a prone position. This intervention optimizes oxygenation by improving ventilation-perfusion matching in ARDS. When the client is in a prone position, there is better distribution of ventilation to the dorsal lung regions, reducing the risk of ventilator-induced lung injury. Choice A is incorrect because low-flow oxygen may not be sufficient to meet the oxygen demands of a client with ARDS. Choice B is incorrect because excessive oral intake can lead to fluid overload in ARDS. Choice C is incorrect because high-protein and high-carbohydrate foods may be difficult for the client to tolerate and can contribute to increased carbon dioxide production.

Question 5 of 5

A client has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Correct Answer: B

Rationale: The correct answer is B: Increasing dyspnea. Atelectasis is a condition where the lung tissue collapses, leading to decreased oxygen exchange and resulting in symptoms like dyspnea (difficulty breathing). This occurs because the collapsed lung tissue reduces the surface area available for gas exchange, leading to decreased oxygen saturation and increased work of breathing. Facial flushing (choice A) is not typically associated with atelectasis. Decreasing respiratory rate (choice C) may not be a reliable indicator as the body may compensate by increasing respiratory rate to maintain oxygenation. Friction rub (choice D) is more commonly associated with conditions like pleurisy or pneumonia, not atelectasis.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days

Similar Questions