ATI RN
Nursing Questions on Oxygenation Questions
Question 1 of 5
A client with pulmonary embolism is receiving anticoagulation therapy. Which lab value requires immediate intervention?
Correct Answer: A
Rationale: Rationale: INR measures the effectiveness of anticoagulation therapy. INR of 1.2 is below the therapeutic range for pulmonary embolism treatment, indicating inadequate anticoagulation and risk of clot progression. Immediate intervention is necessary to adjust medication dosage. Platelet count, aPTT, and hemoglobin levels are within normal range and do not require immediate intervention.
Question 2 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: Rationale: Option B is correct as placing a patient with altered consciousness in a side-lying position helps prevent aspiration by allowing gravity to aid in drainage of secretions and prevents the tongue from obstructing the airway. Turning and repositioning an immobile patient (Option A) helps prevent pressure ulcers but does not directly prevent aspiration. Inserting a nasogastric tube for feeding (Option C) is not a preventive measure for aspiration and may actually increase the risk. Monitoring respiratory symptoms in an immunosuppressed patient (Option D) is important for identifying respiratory infections but does not directly prevent aspiration.
Question 3 of 5
A patient with pneumonia has an oxygen saturation of 88% on room air. Which intervention is most important?
Correct Answer: B
Rationale: The correct answer is B: Initiate oxygen therapy at 2 liters per minute via nasal cannula. Oxygen saturation of 88% indicates hypoxemia, requiring immediate intervention to improve oxygenation. Administering oxygen via nasal cannula at 2 liters per minute can help increase oxygen levels and alleviate symptoms. Choice A (Administer prescribed bronchodilators) is incorrect as bronchodilators are not the first-line treatment for hypoxemia in pneumonia. Choice C (Encourage the use of an incentive spirometer every hour) is incorrect as while important for respiratory hygiene, it does not address the immediate need for oxygen therapy in a hypoxemic patient. Choice D (Increase the patient's fluid intake to thin secretions) is incorrect as it addresses secretion management, which is not the priority in this scenario where oxygenation is compromised.
Question 4 of 5
Which assessment finding in a patient receiving oxygen therapy is most concerning?
Correct Answer: C
Rationale: The correct answer is C: Lethargy and confusion. This is the most concerning assessment finding in a patient receiving oxygen therapy because it indicates potential oxygen deprivation to the brain, which can lead to serious complications. Lethargy and confusion are signs of hypoxia, which can be life-threatening if not addressed promptly. Respiratory rate of 24 breaths per minute (choice A) may indicate increased effort to breathe but is not as immediately concerning as hypoxia. Oxygen saturation of 92% (choice B) is below the normal range but not critically low. Mild nasal dryness (choice D) is a common side effect of oxygen therapy and does not indicate a serious issue with oxygen delivery.
Question 5 of 5
The nurse is teaching a patient about how to manage pleural effusion. Which patient statement indicates understanding?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Pleural effusion can cause shortness of breath. 2. Promptly notifying the healthcare provider about worsening symptoms is crucial. 3. Demonstrates patient understanding of the condition. 4. Enables timely intervention to prevent complications. Summary of why other choices are incorrect: A: Limiting fluid intake may not directly impact pleural effusion. B: Lying flat may not be recommended post-procedure and could worsen symptoms. D: Monitoring every six months is insufficient for a condition that can cause acute symptoms.