ATI RN
NCLEX Practice Questions Oxygenation Questions
Question 1 of 5
A nurse is caring for a patient with a history of diabetes who is experiencing hypoglycemia. What is the priority action?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Administer an antihypertensive. The priority action in a patient with hypoglycemia and a history of diabetes is to rule out other causes of symptoms before assuming it is solely related to blood sugar levels. Administering an antihypertensive can help in managing any potential hypertension, which is crucial in this situation. Administering glucose (Option A) could worsen the hypoglycemia if the patient's symptoms are not solely due to low blood sugar. Administering insulin (Option B) is not appropriate as it would further lower the blood sugar levels. Administering pain relief (Option C) is not the priority in this case unless pain is a known cause of the hypoglycemia. In an educational context, understanding the priority actions in emergency situations is crucial for nurses, especially when dealing with patients with complex medical histories like diabetes. It is essential to assess the patient comprehensively before initiating any interventions to ensure the best possible outcomes.
Question 2 of 5
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?
Correct Answer: C
Rationale: In this scenario, option C is the correct answer. When the patient asks how to clean the tracheostomy stoma and tube, it indicates that the identified problem of hopelessness related to loss of control of personal care is resolving. This question assesses the patient's willingness to engage in self-care activities, demonstrating a return of autonomy and a sense of empowerment. Option A is incorrect because allowing the nurse to suction the tracheostomy does not necessarily reflect the patient's initiative in self-care. Option B is incorrect as reliance on the spouse for daily tracheostomy care does not indicate the patient's independence in managing personal care needs. Option D is also incorrect as using a communication board to request 'No Visitors' does not address the self-care aspect or reflect a positive change in the patient's attitude towards personal care. From an educational perspective, this question highlights the importance of assessing a patient's psychological response to physical changes and loss of control. It emphasizes the nurse's role in promoting patient independence and empowerment in self-care activities to enhance the patient's overall well-being and quality of life. Encouraging patients to ask questions and participate in their care can have a significant impact on their recovery and emotional state.
Question 3 of 5
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness?
Correct Answer: C
Rationale: The correct answer is C) Explain that orange discolored urine and tears are normal while taking this medication. This response demonstrates accurate knowledge about rifampin, a medication commonly used to treat tuberculosis. Rifampin is known to cause harmless side effects such as orange discoloration of bodily fluids, including urine and tears. By explaining this to the patient, the nurse can alleviate concerns and provide reassurance, promoting medication adherence and patient education. Option A) Asking about visual changes in red-green color discrimination is unrelated to the side effects of rifampin and tuberculosis treatment, making this option incorrect. Option B) Inquiring about shortness of breath, hives, or itching is not relevant to the known side effects of rifampin, so this response is incorrect and could lead to unnecessary concern for the patient. Option D) Advising the patient to stop the drug and report symptoms to the healthcare provider is incorrect because the side effects of orange discoloration of urine and tears are expected with rifampin therapy and do not warrant discontinuation of the medication without proper assessment by a healthcare provider. In an educational context, understanding the side effects of medications is crucial for nurses to provide accurate information to patients. By explaining expected side effects like orange discoloration of bodily fluids, nurses can enhance patient understanding, compliance, and overall therapeutic outcomes.
Question 4 of 5
A patient with pneumonia has a fever of 101.4°F (38.6°C), a nonproductive cough, and an O₂ saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?
Correct Answer: D
Rationale: The priority nursing diagnosis in this scenario is "D) Impaired gas exchange related to respiratory congestion." Rationale: Impaired gas exchange is the priority because the patient's O₂ saturation is only 88%, indicating inadequate oxygenation. This poses a serious threat to the patient's health and needs immediate intervention to prevent hypoxia and further complications like respiratory failure. Why others are wrong: A) Hyperthermia related to infectious illness: While fever is present, it is not the immediate threat to the patient's well-being. Oxygenation takes precedence over managing fever. B) Impaired transfer ability related to weakness: While weakness is a concern, it is secondary to the critical issue of impaired gas exchange affecting oxygen delivery to vital organs. C) Ineffective airway clearance related to thick secretions: While this is important, the priority is to ensure that the patient is able to oxygenate adequately to support vital functions. Educational context: Understanding the prioritization of nursing diagnoses is crucial in providing effective and efficient patient care. In acute situations like respiratory distress, addressing impaired gas exchange promptly can make a significant impact on patient outcomes. Nurses must be able to differentiate between urgent and non-urgent issues to prioritize care effectively and ensure patient safety.
Question 5 of 5
The nurse teaches a patient who has asthma about peak flow meter use. Which action by the patient indicates that teaching was successful?
Correct Answer: D
Rationale: The correct answer is D) The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone. This answer is correct because using albuterol in the yellow zone indicates appropriate self-management of asthma exacerbation. Albuterol is a rescue medication that helps to open up the airways quickly during an asthma attack or when peak flow readings drop into the yellow zone, signaling a cautionary phase. Option A is incorrect because inhaling rapidly through the peak flow meter mouthpiece does not reflect proper technique. Option B is incorrect as montelukast is a long-term control medication and is not typically used for immediate symptom relief in the red zone. Option C is also incorrect as calling the healthcare provider when in the green zone is unnecessary as this zone indicates good lung function. Understanding peak flow meter readings and knowing how to respond appropriately based on the zones is crucial in managing asthma effectively. Educating patients on using rescue medications like albuterol in the yellow zone can help prevent asthma exacerbations and improve overall respiratory health.