ATI RN
Oxygen Therapy NCLEX Questions Questions
Question 1 of 5
A client is admitted with acute respiratory failure. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Placing the client in high Fowler's position. This is the priority intervention for a client with acute respiratory failure as it helps improve lung expansion and oxygenation by maximizing chest expansion. Administering a bronchodilator (Choice A) may help with airway patency but placing the client in an upright position takes precedence. Preparing the client for intubation (Choice C) is a more invasive intervention and should be considered after optimizing non-invasive measures. Administering IV antibiotics (Choice D) may be necessary but addressing the immediate respiratory distress by positioning the client correctly is the priority.
Question 2 of 5
A client is diagnosed with pneumothorax. What is the nurse's priority assessment?
Correct Answer: A
Rationale: The correct answer is A: Monitoring for decreased breath sounds on the affected side. This is the priority assessment because pneumothorax involves the accumulation of air in the pleural space, leading to lung collapse and decreased breath sounds on the affected side. This assessment is crucial to promptly detect worsening respiratory status and the need for immediate intervention. Choice B is incorrect because while assessing for bilateral chest rise and fall is important in general respiratory assessment, it is not the priority in pneumothorax where the focus is on the affected side. Choice C is incorrect as cyanosis and tachycardia may occur later as a result of respiratory distress, but monitoring breath sounds is more direct for detecting pneumothorax. Choice D is incorrect because measuring oxygen saturation levels may not accurately reflect the severity of pneumothorax and should not be the priority assessment in this case.
Question 3 of 5
The nurse is caring for a client with cystic fibrosis. What intervention is most effective in improving airway clearance?
Correct Answer: B
Rationale: The correct answer is B: Performing chest physiotherapy regularly. Chest physiotherapy helps mobilize and clear mucus from the airways in cystic fibrosis patients, improving airway clearance. This intervention is essential in preventing respiratory complications. Administering bronchodilators before meals (A) may help with bronchodilation but does not directly address airway clearance. Providing a high-calorie, high-protein diet (C) is important for nutrition but does not specifically target airway clearance. Encouraging the use of a spacer with inhalers (D) may help with medication delivery but does not directly improve airway clearance like chest physiotherapy.
Question 4 of 5
The nurse is teaching a client with asthma about identifying triggers. Which trigger is most commonly associated with asthma attacks?
Correct Answer: A
Rationale: The correct answer is A: Cold air. Cold air is a common trigger for asthma attacks as it can cause airways to constrict and become inflamed, leading to difficulty breathing. Cold air can also worsen existing asthma symptoms. Loud noises (B), lack of sleep (C), and physical inactivity (D) are not typically associated with triggering asthma attacks. Loud noises may exacerbate stress but do not directly trigger asthma. Lack of sleep and physical inactivity can impact overall health but are not primary triggers for asthma attacks.
Question 5 of 5
A client with tuberculosis (TB) is prescribed rifampin. Which side effect should the nurse include in client education?
Correct Answer: A
Rationale: The correct answer is A: Orange discoloration of urine and tears. Rifampin is known to cause harmless orange discoloration of bodily fluids, including urine and tears. This is important for the client to be aware of to prevent unnecessary concern. B: Increased risk of photosensitivity is not a common side effect of rifampin. C: Frequent urination is not a typical side effect of rifampin. D: Sudden weight gain is not a known side effect of rifampin. In conclusion, the correct answer is A because it aligns with a known side effect of rifampin, while the other options are not associated with this medication.