ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 of 5
A nurse is caring for a patient who is experiencing a myocardial infarction (MI). What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer aspirin. Aspirin helps to reduce clot formation and minimize damage during a myocardial infarction (MI). This intervention is a priority because it can potentially save the patient's life by preventing further complications. Administering oxygen therapy (choice A) is important, but aspirin takes precedence due to its immediate impact on the outcome. Administering analgesics (choice C) can be considered after aspirin administration to address pain. Monitoring vital signs (choice D) is essential, but providing aspirin should be the initial priority to address the underlying cause of the MI.
Question 2 of 5
A nurse is caring for a patient with a history of asthma who is experiencing an asthma attack. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer a bronchodilator. During an asthma attack, the priority intervention is to open the airways quickly to improve breathing. Bronchodilators help to relax and widen the air passages, providing immediate relief. Corticosteroids may be used later to reduce inflammation. Reassurance is important but not the priority during an acute attack. Insulin therapy is not relevant to managing an asthma attack.
Question 3 of 5
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The patient is experiencing fluid retention. What is the priority nursing action?
Correct Answer: A
Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps to relieve fluid retention by promoting diuresis through the dilation of blood vessels. Step 1: Assess the patient's condition and identify fluid retention as an issue. Step 2: Administer albuterol as it helps to reduce fluid volume by increasing urine output. Step 3: Monitor the patient for improvement in fluid status. Other choices are incorrect because B: Monitoring blood pressure is important but not the priority in this case. C: Administering IV fluids would worsen fluid retention. D: Administering antihypertensive medications may not directly address the fluid retention issue.
Question 4 of 5
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Inspiratory crackles at the bases. Inspiratory crackles are adventitious lung sounds that are typically heard during inspiration. These low-pitched, bubbling sounds in the lower third of both lungs indicate the presence of fluid or secretions in the alveoli or small airways. The crackles are often described as fine, medium, or coarse based on their intensity. Option B) Expiratory wheezes in both lungs is incorrect because wheezes are typically high-pitched, musical sounds heard during expiration and are associated with narrowed airways, not fluid accumulation. Option C) Abnormal lung sounds in the apices of both lungs is incorrect because crackles are usually heard at the lung bases where dependent lung regions are located, not at the apices. Option D) Pleural friction rub in the right and left lower lobes is incorrect because pleural friction rub is a grating, scratchy sound heard during both inspiration and expiration, and it is caused by inflamed pleural surfaces rubbing together, not by fluid in the alveoli. Providing this educational context helps students understand the importance of recognizing and interpreting lung sounds accurately in clinical practice to guide appropriate interventions and treatment for patients with respiratory issues. By linking pathophysiology to clinical assessment findings, students can enhance their critical thinking skills and develop a deeper understanding of respiratory conditions and their manifestations.
Question 5 of 5
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Correct Answer: C
Rationale: In the context of a patient with a tracheostomy receiving a new order for a fenestrated tracheostomy tube, assessing the ability to swallow before using the fenestrated tube is crucial. Option C is correct because fenestrated tubes are designed to allow for improved speech and facilitate swallowing by directing airflow through the upper airway, which is essential for preventing aspiration. Option A is incorrect because leaving the tracheostomy inner cannula inserted at all times does not address the specific benefits of a fenestrated tube related to speech and swallowing. Option B is incorrect as placing the decannulation cap in the tube before cuff deflation is not directly related to the function of the fenestrated tube in improving swallowing ability. Option D is also incorrect because inflating the tracheostomy cuff during the use of the fenestrated tube would hinder the benefits of the fenestrated design in promoting improved speech and swallowing. Educationally, understanding the rationale behind the use of fenestrated tracheostomy tubes and the importance of assessing swallowing ability before their use enhances a nurse's ability to provide safe and effective care to patients with tracheostomies. It highlights the significance of individualized care and proper collaboration with other healthcare professionals, such as speech therapists, to optimize patient outcomes.