ATI RN
Fundamentals of Nursing Oxygenation Practice Questions Questions
Question 1 of 5
A client with bronchitis is experiencing increased mucus production. Which intervention is most effective in promoting mucus clearance?
Correct Answer: A
Rationale: The correct answer is A: Encouraging fluid intake of at least 3 liters per day. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways. Adequate hydration also helps to keep the mucus membranes moist, facilitating mucus clearance. This intervention promotes effective coughing and expectoration, ultimately aiding in clearing the excess mucus associated with bronchitis. Choice B: Administering prescribed antitussive medication would not be effective in promoting mucus clearance as antitussives suppress coughing, which is needed to clear mucus. Choice C: Positioning the client in a high Fowler's position may improve breathing but does not directly address mucus clearance. Choice D: Limiting activity to conserve energy does not promote mucus clearance. In fact, some degree of activity can help mobilize mucus and facilitate its clearance.
Question 2 of 5
The nurse is planning to care for a client with COPD who has a high anxiety level that causes shortness of breath. Which action should the nurse take given the client's reaction to anxiety?
Correct Answer: B
Rationale: The correct answer is B: Teach pursed-lip breathing to use when feeling anxious. This intervention helps the client manage anxiety-induced shortness of breath by promoting relaxation and improving oxygen exchange. Pursed-lip breathing slows down the client's breathing rate, reduces respiratory rate, and decreases the work of breathing. It also helps to prevent air trapping in the lungs. Administering anti-anxiety medication (Option A) should not be the first-line intervention for managing anxiety-induced shortness of breath. Discouraging visitors (Option C) may isolate the client and not address the underlying issue of anxiety. Teaching proper use of inhalers (Option D) is important for managing COPD symptoms, but it does not directly address anxiety-related shortness of breath.
Question 3 of 5
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?
Correct Answer: D
Rationale: The correct answer is D. The most important result to report immediately is a pH of 7.31, which indicates acidosis, a potentially life-threatening condition. A low pH can lead to organ dysfunction and requires prompt intervention. The other choices have pH levels within normal limits. PaO2, PaCO2, and O2 saturation are also important, but in this case, the critical value is the pH. Choices A, B, and C have pH values closer to normal range and, although abnormalities in PaO2, PaCO2, or O2 saturation should be monitored, they are not as urgent as a pH indicating acidosis.
Question 4 of 5
A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. Which finding indicates the need for immediate intervention?
Correct Answer: C
Rationale: The correct answer is C because the high-pressure alarm on the ventilator sounding indicates that the patient is experiencing increased airway pressure, which can lead to barotrauma and compromise ventilation. Immediate intervention is required to prevent lung injury. Choice A (respiratory rate of 22 breaths/min) is within the normal range and does not indicate an urgent need for intervention. Choice B (arterial oxygen saturation of 89%) is low but may not require immediate intervention as long as it is not rapidly declining and other factors are stable. Choice D (patient attempting to remove the endotracheal tube) is concerning but may not require immediate intervention as long as the airway is still secured, and other parameters are stable.
Question 5 of 5
The nurse observes a student performing tracheostomy care. Which action by the student requires correction?
Correct Answer: B
Rationale: The correct answer is B because changing the tracheostomy ties before cleaning the stoma can lead to contamination of the stoma site. The correct sequence should be to first clean the stoma with saline solution, then change the tracheostomy ties, and finally apply a new sterile dressing. This helps prevent infection and ensures proper hygiene. Choices A, C, and D are incorrect because using sterile technique for suctioning, applying a new sterile dressing, and cleaning the stoma with saline solution are all appropriate actions in tracheostomy care.