ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 of 5
A nurse is caring for a patient with a history of diabetes who is experiencing dizziness and weakness. What is the priority action?
Correct Answer: B
Rationale: The correct answer is B: Administer glucagon. Glucagon is the hormone that raises blood glucose levels quickly in cases of hypoglycemia, which can cause dizziness and weakness in diabetic patients. Administering oral glucose (choice A) may take longer to raise blood sugar levels. Administering insulin (choices C and D) would lower blood glucose levels further, worsening the patient's symptoms. The priority is to quickly raise blood sugar levels to prevent further complications.
Question 2 of 5
A nurse is caring for a patient with a history of chronic kidney disease (CKD). The patient is experiencing fluid retention. What is the priority nursing action?
Correct Answer: A
Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps to relieve fluid retention by promoting diuresis through the dilation of blood vessels. Step 1: Assess the patient's condition and identify fluid retention as an issue. Step 2: Administer albuterol as it helps to reduce fluid volume by increasing urine output. Step 3: Monitor the patient for improvement in fluid status. Other choices are incorrect because B: Monitoring blood pressure is important but not the priority in this case. C: Administering IV fluids would worsen fluid retention. D: Administering antihypertensive medications may not directly address the fluid retention issue.
Question 3 of 5
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
Correct Answer: A
Rationale: Low-pitched, bubbling sounds during inhalation are characteristic of inspiratory crackles, typically heard at the bases when fluid is present.
Question 4 of 5
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Correct Answer: C
Rationale: Fenestrated tubes allow speech and swallowing; assessing swallow ability is critical to prevent aspiration.
Question 5 of 5
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Correct Answer: B
Rationale: A side-lying position reduces aspiration risk in patients with altered consciousness by preventing gastric contents from entering the airway.