ATI RN
NCLEX Oxygenation Practice Questions Questions
Question 1 of 5
A nurse is caring for a patient with a history of myocardial infarction (MI). What is the priority action?
Correct Answer: A
Rationale: In this scenario, the priority action for a patient with a history of myocardial infarction (MI) is to administer aspirin (Option A). Aspirin is crucial in this situation because it helps prevent further clot formation by inhibiting platelet aggregation, thus reducing the risk of subsequent cardiac events. Administering oxygen therapy (Option B) may be important in some cases of MI to ensure adequate oxygenation, but in this specific situation, addressing the underlying cause of the MI is the priority. Administering short-acting bronchodilators (Option C) is more relevant in managing respiratory conditions like asthma or COPD, not in the immediate care of a patient with MI. Administering pain relief (Option D) is important but not the priority over aspirin, which directly addresses the pathophysiology of MI. Educationally, understanding the rationale behind prioritizing interventions in a patient with MI is essential for nurses preparing for the NCLEX exam. It tests the ability to prioritize care based on the patient's condition and the urgency of interventions to achieve optimal outcomes. This question highlights the critical thinking skills necessary for providing safe and effective care to patients with cardiovascular conditions.
Question 2 of 5
The nurse observes that a patient with respiratory disease experiences a decrease in SpO₂ from 93% to 88% while the patient is ambulating. What is the priority action of the nurse?
Correct Answer: B
Rationale: The correct answer is B) Administer PRN supplemental O₂. Rationale: In this scenario, the priority action of the nurse is to administer supplemental oxygen to the patient experiencing a decrease in SpO₂ levels while ambulating. A drop from 93% to 88% indicates hypoxemia, which can lead to serious complications such as tissue damage or organ failure. Administering supplemental oxygen helps to improve oxygenation and prevent further deterioration of the patient's condition. Option A) Notify the health care provider: While it is important to keep the healthcare provider informed, administering oxygen to correct hypoxemia is the immediate priority to ensure patient safety. Option C) Document the response to exercise: Documenting the response is essential for tracking the patient's progress, but it should not take precedence over addressing the immediate oxygenation needs of the patient. Option D) Encourage the patient to pace activity: While pacing activity can be beneficial for patients with respiratory disease, in this acute situation of decreased SpO₂ levels, administering supplemental oxygen is the more critical intervention to address the hypoxemia promptly. Educational context: Understanding how to prioritize interventions based on assessment findings is crucial for nurses, especially when caring for patients with respiratory diseases. Monitoring oxygenation levels and responding promptly to any signs of hypoxemia are essential nursing skills to ensure patient safety and prevent complications related to inadequate oxygenation. Administering supplemental oxygen is a common intervention used to address hypoxemia quickly and effectively in clinical practice.
Question 3 of 5
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, 'Will I be able to talk normally after surgery?' What is the most accurate response by the nurse?
Correct Answer: C
Rationale: The correct answer is C) "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." This response is the most accurate because a total laryngectomy involves the removal of the larynx, which results in the loss of normal speech. Patients who undergo this procedure will require rehabilitation to learn alternative methods of communication, such as esophageal speech or the use of a voice prosthesis. Option A is incorrect because it inaccurately states that the patient will not be able to communicate orally, which is not entirely true as there are methods available for voice restoration post-surgery. Option B is incorrect as it oversimplifies the situation by implying that speech will return once the tracheostomy tube is removed, which is not the case for a total laryngectomy patient. Option D is incorrect because it suggests that the patient can speak normally with artificial voice devices, which may not fully restore natural speech patterns and does not address the need for voice rehabilitation. In an educational context, it is crucial for nurses to provide accurate and realistic information to patients undergoing such procedures to help them understand the changes they will experience and the resources available for support and rehabilitation post-surgery. This empowers patients to make informed decisions and prepares them for the challenges and adjustments they may face in their communication abilities.
Question 4 of 5
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
Correct Answer: C
Rationale: In this NCLEX practice question, option C - "My spouse will sleep in another room" indicates that the teaching on the transmission of pulmonary tuberculosis was effective. This is because TB is an airborne disease that spreads through respiratory droplets. By having the spouse sleep in another room, the risk of transmitting the disease is reduced. Option A - "I will take the bus instead of driving" is incorrect as mode of transportation does not significantly affect TB transmission. Option B - "I will stay indoors whenever possible" is incorrect as TB transmission is more likely in crowded indoor spaces. Option D - "I will keep the windows closed at home" is incorrect as fresh air and ventilation actually help reduce the concentration of infectious droplets in the air. Educationally, this question emphasizes the importance of understanding the modes of transmission of infectious diseases like TB. It highlights the need for patients to take specific actions to prevent the spread of such diseases to others, which is crucial for both their own health and the health of those around them.
Question 5 of 5
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?
Correct Answer: C
Rationale: The most important information to communicate to the health care provider in this scenario is option C - "The patient has a cough that is productive of blood-tinged mucus." This symptom indicates hemoptysis, a serious complication of active tuberculosis that requires immediate attention as it can be life-threatening. Communicating this information promptly allows for timely assessment and intervention to prevent further complications. Option A, the Mantoux test induration of 7 mm, is less urgent as it simply indicates a positive reaction to the TB test but does not require immediate intervention. Option B, infiltrates in the lower lobes on chest x-ray, while concerning, may not be as critical as hemoptysis in terms of immediate intervention. Option D, the patient being treated with antiretrovirals for HIV, is important information but not as urgent in this context as the presence of hemoptysis. Educationally, this question highlights the importance of recognizing priority symptoms in patients with comorbid conditions like HIV and TB. It emphasizes the need for timely communication of critical information to ensure appropriate and prompt medical management, which is vital for patient safety and positive outcomes.