ATI RN
NCLEX Practice Questions Oxygenation Questions
Question 1 of 5
A client is being treated for carbon monoxide poisoning. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A) Administer 100% oxygen via a non-rebreather mask. The top priority in treating carbon monoxide poisoning is to increase the oxygen-carrying capacity of the blood. Carbon monoxide binds to hemoglobin with a much higher affinity than oxygen, leading to tissue hypoxia. By administering 100% oxygen, the nurse helps to displace carbon monoxide from hemoglobin and increase the oxygen saturation in the blood, which is crucial in treating carbon monoxide poisoning. Option B) Monitor for signs of respiratory acidosis is incorrect because while carbon monoxide poisoning can lead to tissue hypoxia, it does not primarily cause respiratory acidosis. Option C) Obtain an arterial blood gas sample is not the priority as initiating treatment to address the hypoxia is more critical before confirming the diagnosis. Option D) Placing the client in a high Fowler's position would not directly address the underlying issue of carbon monoxide poisoning and is not the most urgent intervention in this situation. In an educational context, understanding the priority actions in managing carbon monoxide poisoning is vital for nurses to provide timely and effective care. This scenario highlights the importance of recognizing the pathophysiology of carbon monoxide poisoning and the immediate interventions required to improve oxygenation and patient outcomes.
Question 2 of 5
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Correct Answer: C
Rationale: In this scenario, option C is the correct answer. When coarse crackles are heard in a patient with a tracheostomy tube and they are unable to cough up secretions, suctioning is necessary to clear the airway and prevent respiratory complications. Using a sterile catheter to suction helps remove the secretions effectively. Option A, encouraging increased incentive spirometer use, is incorrect because it focuses on lung expansion rather than directly addressing the need for clearing secretions. Option B, encouraging increased oral fluid intake, is also incorrect as it does not address the immediate need for airway clearance. Option D, preoxygenating the patient before suctioning, is not the priority action when the patient is having difficulty clearing secretions. Educationally, this question highlights the importance of prompt and effective airway management in patients with tracheostomy tubes, especially when abnormal breath sounds are present. Nurses must be adept at recognizing respiratory distress signs and taking appropriate action to maintain airway patency and oxygenation. Mastering these skills is crucial for nurses caring for patients with compromised respiratory function.
Question 3 of 5
The nurse assesses a patient with chronic bronchitis. Which finding is a priority to report to the provider?
Correct Answer: C
Rationale: In the context of a patient with chronic bronchitis, a respiratory rate of 28 breaths per minute is a priority finding to report to the provider because it indicates respiratory distress and potential respiratory failure. This high respiratory rate may suggest inadequate oxygenation, increased work of breathing, and impending respiratory arrest. Prompt intervention is crucial to prevent further deterioration in the patient's condition. Option A: The presence of bilateral ankle edema is concerning for fluid retention, which may be related to heart failure or renal issues. While important, it is not the most immediate concern in a patient with chronic bronchitis. Option B: Green and thick sputum may indicate a bacterial infection, but it is not as urgent as the respiratory distress indicated by a high respiratory rate. Option D: An oxygen saturation of 91% is low and requires monitoring and intervention, but a high respiratory rate takes precedence as it indicates immediate respiratory compromise. In an educational context, understanding the priority of findings in patients with respiratory conditions is crucial for nurses to provide timely and appropriate care. Recognizing signs of respiratory distress and knowing when to escalate care are essential skills for nurses caring for patients with respiratory conditions like chronic bronchitis.
Question 4 of 5
A patient undergoing treatment for tuberculosis reports orange discoloration of bodily fluids. What action should the nurse take?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Explain that this is a normal side effect of the medication. This response is correct because the orange discoloration of bodily fluids is a known side effect of the medication used to treat tuberculosis, specifically rifampin. It is important for the nurse to educate the patient about this side effect to alleviate any concerns and ensure medication adherence. Option A) Discontinuing the medication immediately is not necessary in this case because the orange discoloration is not a sign of a serious adverse reaction requiring immediate cessation of treatment. Option B) Reporting the finding to the healthcare provider may not be needed as this side effect is well-documented and does not typically require medical intervention. Option D) Checking for signs of an allergic reaction is not warranted as the orange discoloration is a known non-allergic side effect of the medication. Educationally, this question highlights the importance of understanding common side effects of medications used in the treatment of tuberculosis. Nurses need to be knowledgeable about medication side effects to provide accurate information and support to patients undergoing treatment. It also emphasizes the need for patient education to address concerns and promote medication adherence.
Question 5 of 5
The nurse evaluates the effectiveness of pursed-lip breathing in a patient with COPD. Which finding indicates improved breathing?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Decreased use of accessory muscles during exhalation. Pursed-lip breathing is a technique commonly used to improve breathing efficiency in patients with COPD by prolonging exhalation, preventing airway collapse, and promoting better gas exchange. When a patient with COPD effectively uses pursed-lip breathing, they experience decreased respiratory effort and reduced reliance on accessory muscles to breathe, leading to improved ventilation and oxygenation. Option B) Increased respiratory rate to 22 breaths per minute is incorrect because an increased respiratory rate may indicate respiratory distress or inadequate gas exchange, which is not a sign of improved breathing in this context. Option C) Oxygen saturation remaining at 88% is incorrect because although oxygen saturation is an important parameter to monitor in COPD patients, it alone does not indicate the effectiveness of pursed-lip breathing. Oxygen saturation may remain the same even if breathing efficiency has improved. Option D) Improved breath sounds bilaterally is incorrect because while improved breath sounds can be a positive sign, they do not directly indicate the effectiveness of pursed-lip breathing in a patient with COPD. It is more important to focus on the patient's respiratory effort and use of accessory muscles to assess the impact of the breathing technique. In an educational context, understanding the rationale behind the correct answer reinforces the importance of therapeutic breathing techniques like pursed-lip breathing in managing COPD. It highlights the goal of reducing respiratory work and improving gas exchange in these patients. Additionally, differentiating between the options helps students develop critical thinking skills and clinical reasoning abilities when evaluating patient responses to interventions.