ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 of 5
A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority?
Correct Answer: A
Rationale: The correct answer is A: Call for the emergency response team to bring the defibrillator. This is the first priority because the patient is experiencing symptoms of a potential cardiac emergency, such as shortness of breath and chest pain. Calling for the emergency response team ensures that the patient can receive immediate medical attention and necessary interventions like defibrillation if needed. Sitting the patient down, applying oxygen, or getting an ECG can be important, but addressing the potential life-threatening cardiac issue takes precedence. It is crucial to prioritize actions that address the most critical and urgent needs of the patient in this situation.
Question 2 of 5
A nurse is planning care for a client at risk of developing ventilator-associated pneumonia (VAP). Which of the following interventions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Elevate the head of the bed to 45 degrees. This intervention helps prevent aspiration and reduces the risk of VAP by promoting proper lung expansion and drainage of secretions. Elevating the head of the bed also decreases the risk of reflux and aspiration of oral secretions. Limiting oral hygiene (A) to once a day can increase the risk of bacterial buildup in the mouth. Performing deep suctioning (C) every 2 hours can cause trauma to the airway and increase the risk of infection. Placing the client in the prone position (D) can lead to decreased lung expansion and impaired secretion drainage, increasing the risk of VAP.
Question 3 of 5
A patient with a history of pulmonary edema is admitted with shortness of breath. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C: Place the patient in a high Fowler's position. This is the priority action because it helps improve oxygenation by reducing pressure on the diaphragm and increasing lung expansion. Elevating the head of the bed also helps decrease the workload of the heart and improves ventilation. Administering diuretics (choice A) can be important but is not the immediate priority. Assessing lung sounds (choice B) is important but not the most critical action at this moment. Notifying the healthcare provider (choice D) can be done after the patient's immediate needs are addressed.
Question 4 of 5
A nurse is providing discharge teaching to a client with pulmonary hypertension. Which statement indicates a need for further teaching?
Correct Answer: B
Rationale: The correct answer is B because taking over-the-counter decongestants can worsen pulmonary hypertension by increasing pulmonary vascular resistance. A is correct as weight monitoring can detect fluid retention. C is correct as strenuous activities can strain the heart. D is correct as increased shortness of breath may indicate worsening condition.
Question 5 of 5
The nurse is caring for a client with cystic fibrosis. Which intervention is the most effective in managing thick mucus secretions?
Correct Answer: C
Rationale: The correct answer is C: Providing chest physiotherapy. This intervention helps mobilize and clear thick mucus secretions in the lungs, improving breathing and preventing infections. Chest physiotherapy involves techniques like percussion and postural drainage to loosen and remove mucus. Encouraging a low-fat diet (choice A) is important for overall health but not directly related to managing mucus secretions. Administering pancreatic enzymes (choice B) is necessary for digestion in cystic fibrosis but does not address mucus clearance. Encouraging daily exercise (choice D) is beneficial for overall lung function but may not be as effective in managing thick mucus secretions as chest physiotherapy.