ATI RN
NCLEX Questions on Oxygenation and Perfusion Questions
Question 1 of 5
A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify which of the following can cause hypoxia?
Correct Answer: B
Rationale: The correct answer is B: Smoke inhalation. Smoke inhalation can cause hypoxia by replacing oxygen in the lungs with harmful gases, leading to a decreased oxygen supply to the body tissues. This can result in tissue damage and impaired cellular function. Diabetic ketoacidosis (choice A) is a metabolic condition characterized by high blood sugar levels, not directly related to hypoxia. Administration of a stimulant medication (choice C) can increase heart rate and blood pressure but does not directly cause hypoxia. Right-sided heart failure (choice D) can lead to fluid accumulation in the body, causing symptoms like edema, but it does not directly cause hypoxia.
Question 2 of 5
A nurse is teaching a client who has a tracheostomy about suctioning. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Suction the tracheostomy for 15 seconds at a time. This instruction is appropriate because prolonged suctioning can lead to tissue damage and hypoxia. Here's a step-by-step rationale: 1. Suctioning for 15 seconds helps prevent hypoxia and mucosal damage. 2. Longer suctioning time can cause trauma to the tracheal mucosa. 3. Adequate oxygenation is crucial during suctioning. 4. Regular breaks between suction passes allow for reoxygenation. Other choices are incorrect: B: Sterile water is not recommended for cleaning the catheter as it may introduce infection. C: Inserting the catheter until resistance is met can cause damage to the trachea. D: Suctioning every hour is not necessary and can lead to potential harm.
Question 3 of 5
The nurse is caring for a client with acute asthma exacerbation. What priority assessment would concern the nurse most?
Correct Answer: C
Rationale: The correct answer is C because inspiratory wheezing and a respiratory rate greater than 30 indicate severe airway obstruction and impending respiratory failure in acute asthma exacerbation. This warrants immediate intervention to prevent respiratory arrest. A: Shortness of breath and low-grade fever are common in asthma exacerbation but not as concerning as severe airway obstruction. B: Low oxygen saturation and elevated pulse rate are also expected in asthma exacerbation but are not as critical as severe airway obstruction. D: Tachycardia and pursed-lip breathing are common in asthma exacerbation but do not indicate severe airway obstruction as clearly as inspiratory wheezing and high respiratory rate.
Question 4 of 5
The nurse is caring for a client with chronic bronchitis who has a productive cough. What intervention should the nurse implement to promote effective airway clearance?
Correct Answer: A
Rationale: Correct Answer: A: Encourage fluid intake of at least 2 liters per day. Rationale: 1. Adequate hydration helps to keep respiratory secretions thin and easier to expectorate. 2. Increased fluid intake helps to prevent dehydration, which can thicken secretions and worsen cough. 3. Hydration is essential for overall health and helps to maintain optimal pulmonary function. Summary: B: Limiting activity may lead to decreased respiratory effort and impaired airway clearance. C: Cough suppressants can hinder the body's natural mechanism to clear secretions. D: Providing supplemental oxygen may help with oxygenation but does not directly promote effective airway clearance.
Question 5 of 5
The nurse is teaching a client with a new diagnosis of COPD about pursed-lip breathing. What is the primary benefit of this technique?
Correct Answer: B
Rationale: The correct answer is B: Reduces airway resistance. Pursed-lip breathing helps to slow down the exhalation process, which in turn reduces the amount of air trapped in the lungs and decreases airway resistance. This technique promotes better oxygen exchange and helps the client breathe more efficiently. A: Increases oxygen intake - Pursed-lip breathing does not directly increase oxygen intake but rather improves the efficiency of oxygen exchange by reducing airway resistance. C: Slows the respiratory rate - While pursed-lip breathing may slow down the breathing pattern, the primary benefit is the reduction of airway resistance, not solely slowing the respiratory rate. D: Prevents hyperventilation - Pursed-lip breathing can help prevent hyperventilation by promoting more controlled breathing, but the primary benefit is the reduction of airway resistance for clients with COPD.