ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?
Correct Answer: D
Rationale: In this scenario, option D, "Tape a nonporous dressing on three sides over the wound," is the correct action for the nurse to take. This is because an occlusive dressing applied on three sides creates a flutter valve effect, allowing air to escape from the wound while preventing air from entering. This technique helps to prevent tension pneumothorax, a potentially life-threatening complication of chest injuries. Option A, "Keep the head of the patient's bed positioned flat," is incorrect because elevating the head of the bed can actually help improve ventilation and oxygenation in patients with chest injuries by allowing for better lung expansion. Option B, "Cover the wound tightly with an occlusive dressing," is incorrect because a fully occlusive dressing can lead to a tension pneumothorax by trapping air within the chest cavity. Option C, "Position the patient so that the left chest is dependent," is also incorrect as this position could potentially exacerbate respiratory distress and compromise oxygenation in a patient with a chest injury. In an educational context, it is crucial for nurses to understand the appropriate interventions for patients with chest injuries to prevent complications like tension pneumothorax. By knowing how to apply a dressing correctly to manage wounds and prevent further harm, nurses can provide effective and potentially life-saving care in emergency situations.
Question 5 of 5
The nurse interviews a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD). Which information is most specific in confirming a diagnosis of chronic bronchitis?
Correct Answer: C
Rationale: The correct answer is C) The patient reports a productive cough for 3 months every winter. This is specific to chronic bronchitis because chronic bronchitis is defined by a productive cough that lasts for at least 3 months in two consecutive years. This information aligns with the diagnostic criteria for chronic bronchitis, making it the most specific indicator in confirming the diagnosis. Option A (The patient tells the nurse about a family history of bronchitis) is incorrect because a family history of bronchitis does not confirm the individual's own diagnosis of chronic bronchitis. Option B (The patient indicates a 30 pack-year cigarette smoking history) is incorrect as it is a risk factor for developing COPD in general but not specific to chronic bronchitis. Option D (The patient denies having respiratory problems until the past 12 months) is incorrect as chronic bronchitis is characterized by a long-standing history of respiratory symptoms, not a sudden onset within the past year. Educationally, understanding the specific diagnostic criteria for chronic bronchitis is crucial for nurses to accurately assess, diagnose, and manage patients with this condition. This question highlights the importance of recognizing key clinical indicators to differentiate between various respiratory conditions.