ATI RN
NCLEX Questions on Oxygen Therapy Questions
Question 1 of 5
A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Auscultate the lung sounds. This should be done first to assess the severity of wheezing and determine if the client's airway is compromised. It helps in making immediate decisions for appropriate interventions like administering bronchodilators or oxygen therapy. Documenting the respiratory rate (B) can be done after assessing lung sounds. Obtaining oxygen saturation (C) is important but not the first priority. Checking capillary refill (D) is not relevant in this situation and can be done later. Overall, assessing lung sounds is crucial in managing a client with asthma and wheezing.
Question 2 of 5
A client with acute respiratory distress syndrome (ARDS) is intubated and placed on mechanical ventilation. What is the priority nursing assessment?
Correct Answer: C
Rationale: The correct answer is C: Ensuring proper endotracheal tube placement. This is the priority assessment because incorrect placement can lead to inadequate oxygenation and ventilation. Step 1: Verify tube placement by auscultating bilateral breath sounds. Step 2: Confirm placement with chest x-ray. Step 3: Assess for signs of respiratory distress to ensure adequate oxygenation. Choices A, B, and D are incorrect because they are important assessments but not the priority in this scenario. Checking for barotrauma (A) and monitoring for ventilator-associated pneumonia (B) are important considerations, but ensuring proper tube placement takes precedence. Assessing for sedation-related complications (D) is also crucial but not the priority assessment in this case.
Question 3 of 5
A client is receiving albuterol for an asthma exacerbation. Which side effect should the nurse monitor for?
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. Albuterol is a beta-2 agonist bronchodilator that can stimulate beta-2 receptors in the heart, leading to tachycardia as a common side effect. This occurs due to the drug's sympathomimetic effects on the heart, increasing heart rate. Bradycardia (A) is not a typical side effect of albuterol. Hypoglycemia (B) is not a direct side effect of albuterol use. Hypotension (D) is less common with albuterol and is more associated with beta-1 receptor effects.
Question 4 of 5
A client receiving mechanical ventilation has high-pressure alarms sounding. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Checking for kinks or obstructions in the tubing. This is the priority action because high-pressure alarms indicate a blockage or restriction in the ventilator circuit, which can lead to inadequate ventilation and hypoxia. By checking for kinks or obstructions first, the nurse can address the immediate issue causing the alarm and ensure the client's safety. Silencing the alarm and notifying the healthcare provider (Choice A) can be done after addressing the alarm cause. Increasing oxygen flow rate (Choice C) may not resolve the issue and could potentially worsen the situation. Suctioning the client immediately (Choice D) is not appropriate without first identifying and addressing the cause of the high-pressure alarms.
Question 5 of 5
The nurse is assessing a client with emphysema. Which finding is most consistent with this condition?
Correct Answer: B
Rationale: The correct answer is B: Barrel-shaped chest. In emphysema, air becomes trapped in the lungs, causing overinflation and the chest to take on a barrel shape. This is due to the destruction of alveoli and loss of elastic recoil in the lungs. Frequent nighttime cough (A) may occur but is not specific to emphysema. Cyanosis (C) is more indicative of inadequate oxygenation, which may occur in emphysema but is not specific. Peripheral edema (D) is not typically associated with emphysema.