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: Low-pitched, bubbling sounds during inhalation are characteristic of inspiratory crackles, typically heard at the bases when fluid is present.
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: Fenestrated tubes allow speech and swallowing; assessing swallow ability is critical to prevent aspiration.