ATI RN
Oxygenation NCLEX Questions Quizlet Questions
Question 1 of 5
A nurse is caring for a patient who is receiving chemotherapy and is experiencing nausea. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer IV fluids. The priority nursing intervention for a patient experiencing nausea while receiving chemotherapy is to administer IV fluids. Chemotherapy can cause dehydration due to vomiting and lack of oral intake, which can lead to electrolyte imbalances and compromised renal function. Administering IV fluids helps maintain hydration, support renal function, and prevent complications. Administering antiemetics (choice A) can help alleviate nausea but does not address the underlying issue of dehydration. Nebulized bronchodilators (choice C) are not indicated for nausea related to chemotherapy. Monitoring vital signs (choice D) is important but not the priority intervention in this case where hydration is the main concern.
Question 2 of 5
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6°F (38.7°C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Obtain a throat culture. Explanation: When a patient presents with symptoms such as anterior cervical lymph node swelling, a fever, and yellow patches on the tonsils, it indicates a high suspicion of a bacterial infection, such as streptococcal pharyngitis (strep throat). A throat culture is necessary to confirm the presence of the bacteria causing the infection. This is crucial for accurate diagnosis and appropriate treatment with antibiotics, as bacterial infections require specific treatment to prevent complications and spread of the infection. Why the other options are incorrect: B) Administering an antipyretic would help reduce the fever but does not address the underlying cause of the symptoms, which is a bacterial infection. Symptomatic relief alone without treating the infection is not sufficient. C) Teaching the patient to gargle with warm salt water may provide some relief for a sore throat but does not address the need for a definitive diagnosis and treatment of a bacterial infection. D) Applying a cool compress to the neck may help reduce discomfort but does not address the need for further assessment and treatment of a bacterial infection causing the symptoms. Educational context: Understanding the rationale behind choosing the correct action in this scenario is essential for nurses to provide safe and effective patient care. By recognizing the signs and symptoms of a bacterial infection in a patient with a sore throat, nurses can demonstrate critical thinking skills in assessing and managing patients with respiratory conditions. This knowledge empowers nurses to advocate for appropriate diagnostic testing and treatment to ensure positive patient outcomes and prevent complications associated with untreated bacterial infections.
Question 3 of 5
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
Correct Answer: D
Rationale: In this scenario, the correct intervention is D) Chest tube connected to suction. This is the most appropriate action because the absent breath sounds and tachycardia indicate a potential pneumothorax, which is a life-threatening condition where air accumulates in the pleural space, causing lung collapse. A chest tube connected to suction is necessary to re-expand the lung by removing the trapped air or fluid. Option A) Emergency pericardiocentesis is incorrect because this procedure involves draining fluid from the pericardial sac around the heart, which is not indicated in this case of suspected pneumothorax. Option B) Stabilization of the chest wall is incorrect as the primary issue here is not related to chest wall stability but rather to the presence of air in the pleural space. Option C) Bronchodilator administration is also incorrect because a bronchodilator is used to treat conditions like asthma or chronic obstructive pulmonary disease (COPD), not for pneumothorax. Educationally, understanding the rationale behind choosing the correct intervention is crucial for nurses to provide safe and effective care in emergency situations. Recognizing the signs and symptoms of pneumothorax and knowing the appropriate intervention of chest tube insertion can potentially save a patient's life by restoring lung function and preventing further complications. This case highlights the importance of quick and accurate assessment skills in emergency care settings.
Question 4 of 5
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?
Correct Answer: B
Rationale: The correct answer for the question regarding the intervention for a patient diagnosed with a lung abscess is option B: Assist the patient with chest physiotherapy and postural drainage. This intervention is crucial because it helps in draining the abscess, facilitating resolution of the condition. Chest physiotherapy can help mobilize secretions, improve ventilation, and aid in the removal of mucus and infected material from the lungs. Postural drainage involves positioning the patient to allow gravity to assist in draining secretions from specific areas of the lungs, which is especially beneficial in cases of lung abscess where drainage is essential for recovery. Option A is incorrect because avoiding over-the-counter expectorants may not address the underlying issue of draining the abscess. Expectoration may be necessary to clear secretions, but it is not the primary intervention for a lung abscess. Option C is incorrect because while notifying the healthcare provider about any changes in sputum characteristics is important for monitoring the patient's condition, it does not directly address the need for interventions to aid in draining the abscess. Option D is incorrect because although prolonged antibiotic therapy is often necessary for treating a lung abscess, it does not address the immediate need for interventions like chest physiotherapy and postural drainage to assist in resolving the abscess. Educationally, understanding the rationale behind each option enhances clinical decision-making skills. By grasping why specific interventions are appropriate or inappropriate for a particular condition, nurses can provide more effective and comprehensive care to their patients, ultimately improving outcomes and promoting patient well-being.
Question 5 of 5
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?
Correct Answer: C
Rationale: The correct answer is C) Give the prescribed albuterol (Ventolin HFA) before the therapy. Albuterol is a bronchodilator that works by opening the airways, which helps in improving airflow and making postural drainage and percussion more effective. By administering albuterol before the therapy, the patient's airways are dilated, making it easier to clear mucus and secretions during the procedure. Option A is incorrect because scheduling the procedure 1 hour after eating is a general recommendation for activities that may cause discomfort if done immediately after a meal, but it is not directly related to the effectiveness of postural drainage and percussion. Option B is incorrect because maintaining the patient in the lateral position for 20 minutes is not a standard part of postural drainage and percussion therapy. The patient's position may vary based on the areas being targeted for drainage. Option D is incorrect because percussion is typically performed after the patient is positioned for drainage. Performing percussion before assisting the patient to the drainage position may not be as effective in mobilizing secretions. Understanding the rationale behind administering albuterol before postural drainage and percussion is essential for nurses caring for patients with respiratory conditions. It demonstrates the importance of optimizing airway function before airway clearance techniques to enhance their effectiveness in promoting effective oxygenation and secretion clearance in patients with chronic bronchitis.