ATI RN
NCLEX Questions on Oxygen Therapy Questions
Question 1 of 5
A client with acute respiratory distress syndrome (ARDS) is intubated and placed on mechanical ventilation. What is the priority nursing assessment?
Correct Answer: C
Rationale: The correct answer is C: Ensuring proper endotracheal tube placement. This is the priority assessment because incorrect placement can lead to inadequate oxygenation and ventilation. Step 1: Verify tube placement by auscultating bilateral breath sounds. Step 2: Confirm placement with chest x-ray. Step 3: Assess for signs of respiratory distress to ensure adequate oxygenation. Choices A, B, and D are incorrect because they are important assessments but not the priority in this scenario. Checking for barotrauma (A) and monitoring for ventilator-associated pneumonia (B) are important considerations, but ensuring proper tube placement takes precedence. Assessing for sedation-related complications (D) is also crucial but not the priority assessment in this case.
Question 2 of 5
A client receiving mechanical ventilation has high-pressure alarms sounding. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Checking for kinks or obstructions in the tubing. This is the priority action because high-pressure alarms indicate a blockage or restriction in the ventilator circuit, which can lead to inadequate ventilation and hypoxia. By checking for kinks or obstructions first, the nurse can address the immediate issue causing the alarm and ensure the client's safety. Silencing the alarm and notifying the healthcare provider (Choice A) can be done after addressing the alarm cause. Increasing oxygen flow rate (Choice C) may not resolve the issue and could potentially worsen the situation. Suctioning the client immediately (Choice D) is not appropriate without first identifying and addressing the cause of the high-pressure alarms.
Question 3 of 5
The nurse is assessing a client with emphysema. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: The correct answer is B: Barrel-shaped chest. In emphysema, air becomes trapped in the lungs, causing overinflation and the chest to take on a barrel shape. This is due to the destruction of alveoli and loss of elastic recoil in the lungs. Frequent nighttime cough (A) may occur but is not specific to emphysema. Cyanosis (C) is more indicative of inadequate oxygenation, which may occur in emphysema but is not specific. Peripheral edema (D) is not typically associated with emphysema.
Question 4 of 5
A client with pulmonary edema is receiving furosemide (Lasix). Which assessment finding indicates the medication is effective?
Correct Answer: A
Rationale: The correct answer is A: Decreased peripheral edema. Furosemide is a diuretic that helps reduce fluid volume in the body, which leads to decreased edema. Peripheral edema is a common manifestation of pulmonary edema, so a decrease in peripheral edema indicates that the furosemide is effectively reducing fluid overload. Increased respiratory rate (B) is a sign of respiratory distress, not medication effectiveness. Blood pressure of 150/90 mmHg (C) is within normal range and not a specific indicator of furosemide effectiveness. Weight gain of 2 kg in 24 hours (D) is a sign of fluid retention and not a desirable outcome when treating pulmonary edema.
Question 5 of 5
The nurse is assessing a client with pleural effusion. Which finding is most expected?
Correct Answer: B
Rationale: The correct answer is B: Dullness to percussion over the affected area. Pleural effusion is an accumulation of fluid in the pleural space, causing dullness to percussion due to the fluid-filled space. Bilateral crackles (A) would suggest a different condition like pulmonary edema. Hyperresonance (C) would be indicative of pneumothorax. Increased fremitus (D) would typically be found in conditions with lung consolidation, such as pneumonia, not pleural effusion. Therefore, the most expected finding in pleural effusion is dullness to percussion over the affected area due to the presence of fluid.