ATI LPN
Fundamentals of Nursing Oxygenation NCLEX Questions Questions
Question 1 of 5
A clients blood gas analysis results show an increase in carbon dioxide level. What will the nurse most likely assess in this client?
Correct Answer: B
Rationale: Elevated $\mathrm{CO} 2$ (hypercapnia) stimulates chemoreceptors triggering increased respiratory rate (B) to expel excess $\mathrm{CO} 2$ the strongest respiratory stimulant. Decreased rate (A) would worsen hypercapnia. Increased blood pressure (C) and decreased bowel sounds (D) are unrelated to $\mathrm{CO} 2$ levels making B the expected assessment finding.
Question 2 of 5
The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a clients medical record. What should this documentation include?
Correct Answer: A
Rationale: Documentation includes lung sounds before and after (A) to assess airway clearance sputum characteristics (B) for infection signs and skin integrity around the stoma (C) for breakdown. Tie knot side (D) is not typically documented. Oxygen flow rate (E not listed) is irrelevant here making A B and C essential for thorough records.
Question 3 of 5
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Correct Answer: D
Rationale: Potassium 5.4 mEq/L. Potassium should be 3.5-5. BUN is 10-20, Creatinine is 0.5-1.1, Sodium is 136-145.
Question 4 of 5
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Subtract the amount of irrigant used from the client's urine output. The client should be supine or dorsal recumbent for maximum access, the open irrigation requires 30-40 ml of fluid, and the nurse will need a 30-50 ml syringe to perform the irrigation.
Question 5 of 5
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
Correct Answer: C
Rationale: Administer the medication into the abdomen. The nurse should instruct the client to insert the needle at 90 to 45 degrees SC. The nurse should not aspirate for blood return as this will cause tissue damage, and so would massaging the site after injection.