ATI RN
NCLEX Oxygenation Practice Questions Questions
Question 1 of 5
A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate?
Correct Answer: C
Rationale: The most appropriate nursing diagnosis for a client with asthma presenting with a respiratory rate of 28 at rest and audible wheezes upon inspiration is option C) Ineffective Breathing Pattern. Rationale for choosing option C: Ineffective Breathing Pattern is the most appropriate nursing diagnosis because the client's respiratory rate of 28 at rest and audible wheezes indicate difficulty in breathing effectively. The wheezing suggests narrowed airways, making it harder for the client to inhale and exhale properly. This diagnosis acknowledges the abnormal breathing pattern seen in asthma and guides nursing interventions to improve ventilation and gas exchange. Rationale for excluding other options: A) Ineffective Airway Clearance: While asthma can lead to mucus production and airway obstruction, the client's symptoms of wheezing and increased respiratory rate point more towards an issue with breathing pattern rather than airway clearance. B) Impaired Tissue Perfusion: This option is not as relevant to the client's immediate respiratory distress and is more associated with issues related to circulation. D) Activity Intolerance: While asthma can lead to activity intolerance due to impaired breathing, the client's current presentation of increased respiratory rate and audible wheezes is more indicative of a breathing pattern problem rather than generalized activity intolerance. Educational context: Understanding how to analyze and interpret client data to determine the most appropriate nursing diagnosis is crucial for providing effective care. In the case of asthma, recognizing the signs and symptoms of ineffective breathing patterns is essential for implementing targeted interventions aimed at improving respiratory function and patient outcomes. By selecting the correct nursing diagnosis, nurses can tailor their care plans to address the specific needs of clients with respiratory conditions like asthma.
Question 2 of 5
The nurse is planning care for the parents of an infant who died as the result of sudden infant death syndrome. Which collaborative interventions does the nurse plan for when providing care to these parents? Select one that doesn't apply.
Correct Answer: C
Rationale: In this scenario, option C, "Schedule a follow-up medical exam," is the correct answer that doesn't apply when providing care to parents of an infant who died as a result of sudden infant death syndrome (SIDS). The rationale behind this is that a follow-up medical exam for the deceased infant is not relevant or necessary. A) Option A, "Refer to grief counseling," is an appropriate intervention as parents dealing with the loss of a child, especially in a sudden and unexpected manner like SIDS, can benefit greatly from professional counseling to navigate their grief. B) Option B, "Provide information on SIDS research," is another relevant intervention as educating parents about SIDS, its risk factors, prevention strategies, and ongoing research can help them understand the condition better and potentially prevent future occurrences. D) Option D, "Offer support group information," is also a valuable intervention as connecting parents with others who have experienced similar loss can provide emotional support, validation, and a sense of community during their grieving process. Educationally, it is important for nurses to understand the unique needs of parents who have lost a child to SIDS and to provide compassionate and appropriate care that addresses their emotional, informational, and support needs. By selecting the correct interventions and understanding why certain options may not be applicable, nurses can offer holistic and effective care to families experiencing such a tragic loss.
Question 3 of 5
What are the various forms of oxygen in the earth's crust?
Correct Answer: A
Rationale: In this question, the correct answer is A) Organic molecules and water. This answer is correct because oxygen in the Earth's crust primarily exists in the form of organic molecules bound within living organisms and in water molecules (H2O) through the process of photosynthesis and respiration. Option B) Ozone and oxygen is incorrect because ozone (O3) is a form of oxygen found in the Earth's atmosphere, primarily in the stratosphere, and is not a significant component of the Earth's crust. Option C) Carbon dioxide and water is incorrect because carbon dioxide (CO2) is a compound composed of carbon and oxygen, but it is not a form of oxygen found in the Earth's crust. Water, while containing oxygen, is not a primary form of oxygen in the crust itself. Option D) None of the above is incorrect as we have established that organic molecules and water are indeed forms of oxygen present in the Earth's crust. From an educational perspective, understanding the forms of oxygen in the Earth's crust is important in environmental science and biology. It is crucial for students to grasp the concept of oxygen's distribution in different Earth reservoirs to comprehend processes like photosynthesis, respiration, and the overall oxygen cycle on our planet. This knowledge also aids in understanding the interconnectedness of living organisms and their environment.
Question 4 of 5
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly?
Correct Answer: C
Rationale: The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.
Question 5 of 5
Ernest Arnold Hamilton, a 60 year old American client was mobbed by teen gangsters near New york, Cubao. He was rushed to John John Hopio Medical Center and was Unconscious. You are his nurse and you are to suction his secretions. In which position should you place Mr. Hamilton?
Correct Answer: D
Rationale: In this scenario, the correct position to place Mr. Hamilton in for suctioning secretions is D) Side lying. Placing a client in a side-lying position helps prevent aspiration during suctioning as it allows drainage of secretions from the mouth. This position also helps maintain proper alignment of the airway, reducing the risk of complications during the procedure. Option A) High fowlers is incorrect because this position is more suitable for clients with respiratory distress to improve lung expansion. However, it is not the ideal position for suctioning secretions as it may increase the risk of aspiration. Option B) Semi fowlers is also not appropriate for suctioning in this case as it does not provide optimal drainage of secretions and may not fully protect the airway. Option C) Prone position is not suitable for suctioning as it can obstruct the airway and make it difficult to effectively clear secretions. In an educational context, it is crucial for nurses to understand the rationale behind positioning clients for interventions like suctioning to ensure the safety and well-being of the client. Proper positioning plays a significant role in maintaining airway patency and preventing complications during procedures. Nurses must be able to assess the client's condition and choose the most appropriate position based on the specific needs of the individual client.