ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 of 5
A client is admitted with carbon monoxide poisoning. What is the nurse's priority action?
Correct Answer: A
Rationale: In the context of carbon monoxide poisoning, the priority action for the nurse is to administer 100% oxygen via a non-rebreather mask (Option A). This is because carbon monoxide has a much higher affinity for hemoglobin than oxygen, leading to tissue hypoxia. By providing high-flow oxygen, the nurse can effectively displace carbon monoxide from hemoglobin and increase the oxygen-carrying capacity of the blood, thereby improving tissue oxygenation. Option B, obtaining a carboxyhemoglobin level, is important for confirming the diagnosis of carbon monoxide poisoning but is not the priority action in an acute situation where immediate intervention is required to improve oxygenation. Option C, placing the client in a hyperbaric oxygen chamber, is a treatment modality for severe cases of carbon monoxide poisoning but may not be readily available or feasible in all healthcare settings. Administering high-flow oxygen is the initial and more practical approach. Option D, initiating continuous pulse oximetry monitoring, is important for ongoing assessment but is not the priority over providing immediate oxygen therapy to address the hypoxia associated with carbon monoxide poisoning. In an educational context, understanding the pathophysiology of carbon monoxide poisoning and the rationale behind the treatment options is crucial for nurses to prioritize interventions effectively in emergency situations. Administering oxygen promptly can be life-saving in cases of carbon monoxide poisoning, making it the priority action for nurses caring for these patients.
Question 2 of 5
A client with COPD is experiencing an exacerbation. Which finding is most concerning?
Correct Answer: D
Rationale: In this scenario, the most concerning finding for a client with COPD experiencing an exacerbation is the use of accessory muscles for breathing (Option D). This indicates severe respiratory distress and impending respiratory failure. Option A, a productive cough with yellow sputum, is a common symptom in COPD exacerbations but does not indicate immediate respiratory compromise. Option B, a respiratory rate of 24 breaths per minute, while elevated, may be seen in COPD exacerbations but is not as critical as the use of accessory muscles. Option C, an oxygen saturation of 88%, is low but may be expected in COPD; however, the use of accessory muscles indicates severe respiratory distress. Educationally, understanding these findings is crucial for nurses to prioritize interventions and escalate care appropriately for clients with COPD exacerbations. Recognizing the significance of accessory muscle use can prompt prompt intervention and prevent respiratory failure, highlighting the importance of ongoing assessment and monitoring in respiratory conditions.
Question 3 of 5
The nurse is caring for a client post-thoracentesis. Which finding requires immediate intervention?
Correct Answer: C
Rationale: In this scenario, option C, "Tracheal deviation to the unaffected side," requires immediate intervention. Tracheal deviation is a critical sign that can indicate tension pneumothorax, a life-threatening emergency where air accumulates in the pleural space under pressure, pushing the mediastinum and trachea to the unaffected side. This compromises cardiac output and can lead to respiratory failure and cardiac arrest. Option A, "Oxygen saturation of 95%," is within the expected range and does not indicate an immediate concern. Option B, "Respiratory rate of 16 breaths per minute," is also within the normal range for an adult and does not signal an urgent issue. Option D, "Mild discomfort at the procedure site," is common after thoracentesis and can be managed with pain relief measures. It does not require immediate intervention unless it worsens or is accompanied by other concerning symptoms. Educationally, it is crucial for nurses to recognize and respond promptly to signs of respiratory distress post-thoracentesis to prevent complications. Understanding the significance of tracheal deviation and differentiating it from expected post-procedure discomfort is vital in providing safe and effective care to patients undergoing thoracentesis.
Question 4 of 5
A client with pneumonia reports persistent fatigue. Which intervention should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A) Encouraging the client to rest between activities. In a client with pneumonia experiencing persistent fatigue, prioritizing rest is crucial for facilitating the body's healing process. Rest helps conserve energy, reduces oxygen demand, and allows the immune system to better fight the infection. By encouraging rest, the nurse supports the client's recovery and prevents further exhaustion. Option B) Providing high-calorie, high-protein meals may be important for overall nutrition and energy levels, but it may not directly address the immediate issue of persistent fatigue in pneumonia. Option C) Increasing oral fluid intake is essential for hydration but may not directly address the root cause of fatigue. Option D) Administering a multivitamin, while important for overall health, may not be the most critical intervention for addressing the client's immediate symptom of fatigue. In an educational context, understanding the priority interventions for clients with pneumonia helps nurses provide effective and individualized care. By focusing on rest as a priority intervention, nurses can optimize outcomes for clients experiencing fatigue due to respiratory infections. Prioritizing care interventions based on clients' specific needs is a fundamental aspect of nursing practice that enhances patient outcomes and promotes holistic care.
Question 5 of 5
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
Correct Answer: D
Rationale: The correct answer is D) Sitting upright with the arms supported on an over-bed table. For a thoracentesis procedure in a patient with a left-sided pleural effusion, positioning the patient sitting upright allows for better access to the pleural space and easier visualization for the healthcare provider performing the procedure. This position helps maximize lung expansion, making it easier to access the pleural effusion. Option A) High-Fowler's position with the left arm extended is incorrect as it does not provide optimal positioning for accessing the pleural effusion on the left side. Option B) Supine with the head of the bed elevated 30 degrees is incorrect because lying flat does not facilitate access to the pleural space. Option C) On the right side with the left arm extended above the head is incorrect as it does not provide the best positioning for accessing the pleural effusion on the left side and may cause discomfort to the patient. In an educational context, understanding the correct positioning for thoracentesis is crucial for providing safe and effective patient care. Proper positioning can impact the success and safety of the procedure, so nurses must be knowledgeable about the rationale behind positioning choices for various patient conditions.