ATI RN
NCLEX Questions on Oxygenation and Perfusion Questions
Question 1 of 5
A nurse is caring for a patient with a history of diabetes who is experiencing blurred vision. What is the priority action?
Correct Answer: C
Rationale: The correct answer is C: Administer insulin. Blurred vision in a patient with a history of diabetes could indicate hyperglycemia. Administering insulin would help lower blood glucose levels and alleviate the blurred vision. Monitoring blood glucose levels (choice A) is important but not the priority when the patient is already experiencing symptoms. Administering insulin (choices B and D) is the immediate action needed to address the high blood glucose levels causing the blurred vision.
Question 2 of 5
A nurse is caring for a patient with a history of asthma. The patient is experiencing shortness of breath. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer a bronchodilator. The priority intervention for a patient with asthma experiencing shortness of breath is to administer a bronchodilator to help open up the airways and improve breathing. Bronchodilators work quickly to relieve acute symptoms of asthma by relaxing the muscles around the airways. This intervention is crucial in managing an acute asthma exacerbation. Summary: - Option B: Administer insulin therapy is incorrect because it is not indicated for managing asthma exacerbation. - Option C: Administer short-acting bronchodilators is partially correct but not as specific as option A, which specifies the immediate need for bronchodilator therapy. - Option D: Administer corticosteroids is important for long-term control of asthma but not the priority intervention in an acute exacerbation where immediate relief is needed.
Question 3 of 5
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO₂ levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Correct Answer: C
Rationale: The correct answer is C - Arrange for the patient's caregiver to be present during the teaching. In the context of a patient with COPD, involving the caregiver in the discharge teaching is crucial for several reasons. COPD is a chronic condition that requires ongoing management and lifestyle modifications. By having the caregiver present, the patient is more likely to receive consistent support and reinforcement of the information provided during the teaching session. This support can help the patient adhere to the prescribed treatment plan, medication regimen, and lifestyle changes, ultimately improving compliance and health outcomes. Option A, having the patient repeat the instructions immediately after teaching, may not be as effective in the case of a chronic condition like COPD where ongoing support is crucial. Option B, accomplishing patient teaching just before discharge, may not allow enough time for the patient and caregiver to fully understand and internalize the information provided. Option D, starting discharge teaching during the admission process, may not be as effective as involving the caregiver who will be providing support post-discharge. In an educational context, this question highlights the importance of considering the holistic needs of patients with chronic conditions like COPD. It emphasizes the role of caregivers in supporting patient education and self-management, promoting better health outcomes and improved compliance with treatment plans.
Question 4 of 5
Which action should the nurse take first when a patient develops epistaxis?
Correct Answer: B
Rationale: The correct answer to the question "Which action should the nurse take first when a patient develops epistaxis?" is option B) Apply squeezing pressure to the nostrils for 10 minutes. This is the recommended initial intervention for epistaxis because applying pressure helps to compress the blood vessels, promoting clot formation and stopping the bleeding. Option A) Packing the affected nare tightly with an epistaxis balloon is a more invasive procedure and should be considered if direct pressure does not control the bleeding. It is not the first-line intervention due to its invasiveness and potential discomfort for the patient. Option C) Obtaining silver nitrate for cauterization is a procedure that should be performed by a healthcare provider and is usually reserved for cases of recurrent or severe epistaxis that do not respond to initial management. It is not the first action to take. Option D) Instilling a vasoconstrictor medication into the affected nare can be considered as an adjunct therapy but is not the initial step. Vasoconstrictors may help constrict blood vessels and reduce bleeding, but direct pressure is the primary intervention to control epistaxis. Educationally, understanding the stepwise approach to managing epistaxis is crucial for nurses and healthcare professionals to provide safe and effective care. Knowing the appropriate sequence of interventions can prevent complications and promote optimal outcomes for patients experiencing epistaxis. Applying the correct initial intervention promptly can help control bleeding and alleviate patient distress.
Question 5 of 5
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
Correct Answer: C
Rationale: The correct answer is C: Arrange for a daily meal and drug administration at a community center. This option is the most effective intervention as it addresses the patient's barriers to adherence, such as homelessness and potential lack of resources for meals. By providing both meals and medication administration at a community center, the nurse ensures that the patient has access to a safe and consistent environment for taking their medications. This approach also allows for directly observed therapy (DOT), which is crucial in the treatment of active TB to ensure medication compliance and reduce the risk of developing drug-resistant strains. Option A is incorrect as simply repeating warnings about infecting others does not address the patient's specific needs related to homelessness and substance abuse. Option B, giving written instructions, may not be effective for a patient who may have difficulty reading or understanding written information due to their circumstances. Option D, arranging for a friend to administer medication, may not be feasible or sustainable in the long term and does not address the underlying issues of homelessness and lack of resources. In an educational context, this question highlights the importance of considering social determinants of health and individual patient circumstances when planning interventions to promote treatment adherence. It emphasizes the need for holistic and patient-centered care, especially in vulnerable populations like the homeless with complex health needs. Nurses must be able to identify barriers to adherence and tailor interventions to address these barriers effectively to ensure optimal patient outcomes.