ATI RN
NCLEX Practice Questions Oxygenation Questions
Question 1 of 5
A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child's respiratory pattern?
Correct Answer: D
Rationale: Aspirin (acetylsalicylic acid) is known to cause metabolic acidosis in children when taken in high doses. Metabolic acidosis can lead to shallow respirations as a compensatory mechanism for the body to try and increase the blood pH by blowing off carbon dioxide (CO2). Shallow breathing helps reduce the amount of CO2 retained in the body, thus reducing serum pH levels. It is important to closely monitor the respiratory status of a child who has been given aspirin, especially with the risk of metabolic acidosis. It is contraindicated to give aspirin to children due to the risk of Reye's syndrome, a rare but serious condition.
Question 2 of 5
The nurse is planning to care for a client with a DX of COPD with a high anxiety level that causes SOB. Which action should the nurse take given the client's reaction to anxiety?
Correct Answer: B
Rationale: The correct answer is B) Teach pursed lip breathing to use when feeling anxious. This is the most appropriate action because pursed lip breathing helps COPD patients manage their shortness of breath by slowing down their breathing rate, promoting better oxygen exchange, and reducing anxiety levels. Teaching this technique empowers the client to actively participate in managing their symptoms. Option A) Administering anti-anxiety medication PRN may provide temporary relief but does not address the underlying issue of anxiety. It is important to teach coping strategies that clients can use independently. Option C) Discouraging visitors who may cause anxiety does not address the client's ability to manage anxiety when they are alone or in other triggering situations. It is essential to equip the client with skills to cope in various circumstances. Option D) Teaching the proper use of inhalers is important for managing COPD symptoms but does not directly address the client's anxiety level. Separating the management of COPD symptoms from anxiety management is crucial for comprehensive care. In an educational context, teaching clients coping strategies like pursed lip breathing empowers them to take an active role in managing their condition. By providing practical tools to address anxiety, nurses can improve the client's quality of life and promote self-care and independence in managing their COPD.
Question 3 of 5
The nurse is preparing to discharge a client with sleep apnea. Which intervention is most appropriate to include in the teaching plan?
Correct Answer: B
Rationale: Rationale: The correct answer is B) Lose weight if you are overweight. This is the most appropriate intervention because excess weight can contribute to the development or exacerbation of sleep apnea. By losing weight, the client can reduce the amount of soft tissue in the throat area that may block the airway during sleep, improving breathing patterns and reducing apnea episodes. Option A) Sleep on your back to maintain an open airway is incorrect as sleeping on the back can actually worsen sleep apnea by causing the tongue and soft tissues to collapse into the airway, leading to obstruction. Option C) Avoid using CPAP if symptoms improve is incorrect because CPAP (Continuous Positive Airway Pressure) is a common and effective treatment for sleep apnea. It helps keep the airway open during sleep by delivering a continuous flow of air through a mask. Option D) Limit fluid intake before bedtime is also incorrect as it may help reduce the frequency of nighttime awakenings to urinate, but it does not directly address the underlying issue of sleep apnea. In an educational context, teaching clients about the relationship between weight and sleep apnea is crucial. By understanding how weight can impact their condition, clients can make informed lifestyle changes to improve their symptoms and overall health. It is important for nurses to provide evidence-based education to empower clients in managing their sleep apnea effectively.
Question 4 of 5
A client with emphysema is receiving oxygen therapy at 2 L/min. The client reports increasing shortness of breath. What is the nurse's priority action?
Correct Answer: C
Rationale: In this scenario, the nurse's priority action should be option C: assess the client's respiratory status and oxygen saturation. This is the correct answer because when a client with emphysema on oxygen therapy reports increasing shortness of breath, it is crucial to first assess their current respiratory status and oxygen saturation levels. These assessments provide immediate information about the client's oxygenation status and help the nurse determine the appropriate next steps in care. Option A, increasing the oxygen flow rate to 4 L/min, is not the priority action because changing the oxygen flow without assessing the client's status can be potentially harmful. It is important to gather data before making any adjustments to the oxygen therapy. Option B, notifying the healthcare provider immediately, is also not the priority at this moment. While it is essential to involve the healthcare provider in the client's care, assessing the client's condition should come first to provide timely and appropriate interventions. Option D, positioning the client in high Fowler's position, may help improve ventilation but does not address the immediate need to assess the client's respiratory status and oxygen saturation levels. In an educational context, this question highlights the significance of prioritizing assessments in nursing care. It reinforces the importance of data collection and critical thinking in making clinical decisions. Understanding the rationale behind prioritizing actions based on assessment findings is crucial for safe and effective nursing practice, especially in situations where prompt interventions are necessary to ensure patient safety and well-being.
Question 5 of 5
A client with COPD is prescribed tiotropium (Spiriva). What should the nurse include in the teaching plan?
Correct Answer: B
Rationale: In the context of a client with COPD being prescribed tiotropium (Spiriva), option B, "This medication is used for long-term management, not quick relief," is the correct answer. This is because tiotropium is a long-acting bronchodilator that helps to manage COPD symptoms over time by improving lung function and reducing exacerbations. It is not meant for immediate relief of symptoms during exacerbations, as stated in option A. Option C, "Avoid eating grapefruit while taking this medication," is incorrect as there is no known interaction between tiotropium and grapefruit. Option D, "Take the medication with food to prevent stomach upset," is also incorrect as tiotropium is typically taken on an empty stomach. In an educational context, it is crucial for nurses to understand the rationale behind medication administration to provide effective patient education. By emphasizing that tiotropium is a long-term management medication, nurses can ensure that patients use it correctly to achieve optimal therapeutic outcomes in the management of COPD. This knowledge helps in promoting patient adherence and self-management in the long-term care of COPD.