ATI RN
Oxygen Therapy NCLEX Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
Correct Answer: C
Rationale: The correct answer is C: Discontinuous, high-pitched sounds of short duration during inspiration. In heart failure, the patient may develop pulmonary edema leading to crackles or fine rales on auscultation, which are best heard during inspiration due to the opening of collapsed alveoli. This is characterized by short-duration, high-pitched sounds. Option A is more indicative of rhonchi, commonly heard in conditions like bronchitis. Option B describes wheezes typically found in asthma or COPD. Option D describes coarse crackles, which are heard in conditions like pneumonia. Therefore, the most likely finding in a patient with early heart failure would be discontinuous, high-pitched sounds during inspiration.
Question 5 of 5
Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with chest physiotherapy and postural drainage. This intervention helps mobilize secretions in the lungs, aiding in the drainage of the abscess. Chest physiotherapy can improve ventilation and oxygenation. A: Avoiding over-the-counter expectorants is not directly related to managing a lung abscess. They may not be effective for this condition. C: Notifying the healthcare provider about bloody or foul-smelling sputum is important, but it is not a direct intervention for managing a lung abscess. D: Teaching about the need for prolonged antibiotic therapy is important, but the immediate intervention for a lung abscess is to assist with chest physiotherapy and postural drainage to improve outcomes.