ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
A nurse is caring for a patient with a history of hypertension who is complaining of dizziness and headache. What is the priority action?
Correct Answer: D
Rationale: The correct answer is D: Administer oral antihypertensives. The priority action for a patient with hypertension experiencing dizziness and headache is to address the underlying cause of the symptoms, which is likely elevated blood pressure. Administering oral antihypertensives will help lower the patient's blood pressure and alleviate the symptoms. Explanation: 1. Assess the patient's vital signs to confirm hypertension. 2. Administering oral antihypertensives is a quick and effective way to lower blood pressure. 3. Monitoring the patient's response to the medication is crucial. 4. Administering oxygen therapy (Choice C) is not the priority as the symptoms are likely due to hypertension, not hypoxia. 5. Administering antihypertensive medication (Choice A) or a beta-blocker (Choice B) via other routes may not be as quick or effective as oral medications.
Question 2 of 5
A nurse is caring for a patient with a history of stroke who is exhibiting facial drooping. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer pain relief. In a patient exhibiting facial drooping, the priority intervention is to assess for stroke symptoms, specifically to rule out a current stroke. Administering pain relief can help determine if the drooping is due to a stroke or another cause. Administering nitroglycerin (B) is not appropriate for facial drooping. Monitoring oxygen saturation levels (C) is important but not the priority in this situation. Administering analgesics (D) is similar to pain relief but does not address the urgency of assessing for stroke symptoms.
Question 3 of 5
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
Correct Answer: D
Rationale: The correct answer is option D, sitting upright with the arms supported on an over bed table, for several reasons. Firstly, this position allows gravity to assist in moving the fluid away from the puncture site, making it easier to access the pleural space during thoracentesis. Secondly, sitting upright promotes lung expansion, making it easier for the healthcare provider to insert the needle accurately. Additionally, supporting the arms on an over bed table helps the patient maintain a steady position and reduces the risk of accidental movement during the procedure. Option A, High-Fowler's position with the left arm extended, is incorrect because while the patient is upright, extending the left arm may not provide optimal access to the pleural space on the left side. Option B, supine with the head of the bed elevated 30 degrees, is incorrect as this position does not facilitate gravity-assisted drainage of the pleural effusion or optimal lung expansion. Option C, on the right side with the left arm extended above the head, is also incorrect as it does not provide easy access to the pleural space on the left side and may not promote optimal lung expansion. In an educational context, it is crucial for nurses to understand the rationale behind positioning patients for procedures like thoracentesis to ensure the safety, comfort, and effectiveness of the intervention. Proper positioning can impact the success of the procedure and the patient's overall well-being. This knowledge is essential for nurses who work in settings where thoracentesis is performed and for those preparing for exams like the NCLEX that assess their clinical reasoning skills.
Question 4 of 5
The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?
Correct Answer: B
Rationale: In this scenario, option B is the correct answer because the statement about using nasal decongestant spray until the congestion is gone indicates a need for additional teaching. Prolonged use of decongestant sprays can lead to a rebound effect, worsening congestion in the long run. This is a crucial point to understand in managing acute sinusitis. Option A is incorrect because staying well hydrated is a beneficial practice to help thin mucus and alleviate congestion. Option C is incorrect as acetaminophen can be used to manage sinus discomfort and pain. Option D is also incorrect because monitoring changes in nasal secretions and sputum is an important part of self-care management to assess for worsening symptoms or potential complications. In an educational context, it is essential for patients to understand the appropriate and safe use of medications and home remedies for managing upper respiratory infections like acute sinusitis. Teaching patients about potential risks of overusing certain medications, like decongestant sprays, is crucial to prevent complications and promote effective symptom management. Empowering patients with accurate information helps them make informed decisions about their health and well-being.
Question 5 of 5
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
Correct Answer: C
Rationale: The correct answer is C) Assist the patient to splint the chest when coughing. This option is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia presenting with coarse crackles and thick sputum. By splinting the chest during coughing, the patient can effectively mobilize and expel the thick sputum, which helps clear the airways and improve oxygenation. Option A) Restricting oral fluids during the day is incorrect as hydration is crucial in thinning the sputum, making it easier to cough up and clear the airways. Dehydration can lead to thicker secretions, exacerbating the problem. Option B) Teaching the pursed-lip breathing technique is beneficial for patients with chronic lung conditions like COPD to improve oxygen exchange. However, in a patient with bacterial pneumonia and thick sputum, the priority is to facilitate the removal of secretions through effective coughing rather than focusing solely on breathing techniques. Option D) Encouraging the patient to wear the nasal O₂ cannula may be necessary for supplemental oxygen therapy in some cases of pneumonia, but it does not directly address the issue of airway clearance. Oxygen therapy aims to improve oxygenation but does not specifically aid in mobilizing and clearing the sputum from the airways. In an educational context, understanding the rationale behind each option helps nurses make informed clinical decisions based on the patient's condition. By prioritizing interventions that directly address the underlying issue, such as promoting airway clearance in this scenario, nurses can provide optimal care and improve patient outcomes. Encouraging critical thinking and clinical reasoning skills through NCLEX-style questions helps reinforce the importance of evidence-based practice in nursing care.