ATI RN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Monitor the client for subcutaneous emphysema. Subcutaneous emphysema is a potential complication of a chest tube insertion, characterized by air trapped under the skin. The nurse should assess the client for signs like a crackling sensation upon palpation. This action is crucial as early detection can prevent serious complications. Choices B and C are incorrect. Continuous bubbling in the water seal chamber indicates an air leak, which should be reported immediately. Keeping the drainage system above the chest level can lead to backflow of drainage into the client, increasing the risk of infection. Choice D is incorrect as clamping the chest tube during ambulation can cause a tension pneumothorax.
Question 2 of 5
The nurse is evaluating the effectiveness of oxygen therapy in a client with hypoxemia. Which finding indicates improvement?
Correct Answer: B
Rationale: The correct answer is B because an increase in oxygen saturation from 88% to 95% indicates improved oxygenation in the blood, reflecting the effectiveness of oxygen therapy. This improvement directly addresses the underlying issue of hypoxemia. A: Respiratory rate decreasing may indicate improvement, but it is not as specific to oxygenation as oxygen saturation levels. C: Heart rate decreasing could be a sign of improvement, but it is not as directly related to oxygen therapy effectiveness as oxygen saturation levels. D: Client reporting reduced fatigue is subjective and may not always correlate with objective improvement in oxygenation levels.
Question 3 of 5
A client with a tracheostomy is at risk for aspiration. What intervention should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Position the client in high Fowler's position during meals. This helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the tracheostomy. Keeping the client NPO (A) is not necessary unless directed by a healthcare provider. Suctioning the tracheostomy frequently (C) can increase the risk of infection and is only done when there is visible secretions. Providing thickened liquids (D) may still pose a risk of aspiration, so positioning is more effective in preventing this complication.
Question 4 of 5
The nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which intervention is most likely to improve oxygenation?
Correct Answer: B
Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position helps improve oxygenation in ARDS by optimizing ventilation-perfusion matching, reducing ventilation-perfusion mismatch, and improving lung mechanics. This position allows for better distribution of ventilation to the dorsal lung regions, improving oxygenation. Increasing oxygen flow rate (A) may not address the underlying issue of ventilation-perfusion mismatch. Performing frequent oral suctioning (C) is important for airway clearance but may not directly improve oxygenation. Administering a bronchodilator (D) may help in conditions like asthma but is not typically used in ARDS where the primary issue is not bronchoconstriction.
Question 5 of 5
A nurse is caring for a client receiving high-flow oxygen therapy. Which complication should the nurse monitor for?
Correct Answer: A
Rationale: The correct answer is A: Oxygen toxicity. High-flow oxygen therapy can lead to oxygen toxicity, causing lung damage and respiratory failure. The nurse should monitor for signs such as dyspnea, cough, chest pain, and hypoxemia. Other choices are incorrect because: B: Pulmonary embolism is a complication of blood clots traveling to the lungs, not directly related to high-flow oxygen therapy. C: Carbon dioxide retention is more likely to occur in patients with chronic lung disease and not specifically related to high-flow oxygen therapy. D: Pneumothorax is the accumulation of air in the pleural space, which can happen spontaneously or due to trauma, not directly caused by high-flow oxygen therapy.