ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 of 5
A nurse is caring for a patient who is receiving mechanical ventilation. The patient is exhibiting signs of respiratory distress. What is the priority intervention?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Check the ventilator settings. This is the priority intervention because the patient's signs of respiratory distress indicate a potential issue with the mechanical ventilation. Checking the ventilator settings allows the nurse to assess if the settings are appropriate for the patient's current condition and make any necessary adjustments to improve oxygenation. Monitoring the patient's blood pressure (option B) is important in overall patient assessment, but in this case, addressing the respiratory distress takes precedence as it directly impacts oxygenation and can lead to serious complications if not managed promptly. Administering IV fluids (options C and D) is not the priority in this situation as the patient is experiencing respiratory distress, which requires immediate attention to ensure adequate oxygenation. IV fluids may be needed depending on the patient's overall condition, but addressing the respiratory distress should come first to prevent further deterioration. In an educational context, understanding the priority interventions in a critical care setting like mechanical ventilation is crucial for nurses to provide safe and effective care. By prioritizing actions based on the patient's condition, nurses can intervene promptly to optimize outcomes and prevent complications related to oxygenation.
Question 2 of 5
A nurse is caring for a patient with a history of diabetes. The patient is complaining of blurry vision. What is the priority action?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Administer insulin. The priority action is to address the patient's complaint of blurry vision, which can be a sign of hyperglycemia in a patient with diabetes. Administering insulin is crucial to lower the elevated blood glucose levels that may be causing the blurry vision and prevent potential complications like diabetic retinopathy. Option A) Monitor blood glucose levels is not the priority in this situation because the patient is already experiencing symptoms of hyperglycemia, and prompt intervention is needed. Option B) Administer a nebulizer is not relevant to the patient's complaint of blurry vision, which is likely related to the uncontrolled blood glucose levels. Option D) Monitor vital signs is important but not the immediate priority when the patient is experiencing a symptom that indicates a potential diabetic emergency. Educationally, this question highlights the importance of recognizing early signs of hyperglycemia in patients with diabetes and the need for prompt intervention to prevent complications. Understanding the link between diabetes, hyperglycemia, and ocular complications is crucial for nurses to provide safe and effective care for diabetic patients.
Question 3 of 5
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
Correct Answer: A
Rationale: The correct answer is A) Allergy to shellfish. Communicating this information to the health care provider is a priority before the CT scan because the patient may have a contrast dye allergy, often derived from shellfish, which could lead to a severe allergic reaction during the scan. This crucial information allows the provider to take necessary precautions to prevent a potentially life-threatening situation. Option B) Apical pulse of 104 is not the priority as it may be within normal limits considering the patient's acute dyspnea. Option C) Respiratory rate of 30 is also important but not as critical as the allergy information. Option D) O₂ saturation of 90% is concerning but may be due to the underlying dyspnea, whereas the allergy poses an immediate risk. Educationally, this question highlights the importance of thorough assessment and communication of critical information to ensure patient safety during diagnostic procedures. It emphasizes the significance of recognizing and prioritizing patient data to guide appropriate nursing interventions and collaborative care with healthcare providers.
Question 4 of 5
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A) A patient who is complaining of a sore throat and has a muffled voice should be assessed first in the ENT clinic. This patient's symptoms could indicate a potential airway obstruction, such as an abscess or swelling in the throat, which could rapidly progress to a life-threatening situation. Prompt assessment and intervention are crucial in this scenario. Option B) is incorrect because while the positive rapid strep test indicates a bacterial infection, it does not pose an immediate threat to the patient's airway or respiratory status, unlike a potential airway obstruction. Option C) is incorrect as severe fatigue in a patient receiving radiation for throat cancer is concerning but does not pose an immediate risk to the patient's airway or respiratory status. Option D) is incorrect because while redness and inflammation around a stoma in a patient with a laryngectomy are concerning for infection, it is not as urgent as the potential airway compromise presented by the symptoms in option A. Educationally, this question highlights the importance of prioritizing patient care based on the urgency of the situation, particularly in an ENT setting where respiratory compromise can quickly become life-threatening. Nurses must be able to quickly assess and prioritize patients based on their clinical presentation to ensure the best outcomes for their patients.
Question 5 of 5
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?
Correct Answer: B
Rationale: In this scenario, option B, where the student nurse applies a surgical face mask before visiting the patient with active tuberculosis, would require intervention by the nurse. This is because surgical masks are not effective in preventing the transmission of TB, and the appropriate personal protective equipment (PPE) for TB includes an N95 respirator mask. Option A is incorrect because offering a tissue to the patient does not pose a risk of spreading TB. Option C is incorrect as bringing a snack to the patient would not impact the spread of TB. Option D is also incorrect because hand washing is a standard precaution and should be performed before entering any patient's room, not just for TB. From an educational standpoint, this question highlights the importance of understanding the appropriate precautions for infectious diseases like tuberculosis. It emphasizes the significance of using the correct PPE to prevent the transmission of airborne diseases and the need for proper infection control measures to ensure patient and healthcare provider safety.