ATI RN
Oxygenation NCLEX Questions Quizlet Questions
Question 1 of 5
A nurse is caring for a patient with a history of hypertension who is experiencing chest pain. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer morphine. Chest pain in a patient with a history of hypertension may indicate a myocardial infarction. Morphine is essential to alleviate pain and reduce myocardial oxygen demand. Nitroglycerin may lower blood pressure, which can be dangerous in a hypertensive patient. Aspirin is important for antiplatelet effects but not the immediate priority. Administering an antihypertensive is not necessary as the priority is managing chest pain.
Question 2 of 5
A nurse is caring for a patient who is receiving chemotherapy and is experiencing nausea. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer IV fluids. The priority nursing intervention for a patient experiencing nausea while receiving chemotherapy is to administer IV fluids. Chemotherapy can cause dehydration due to vomiting and lack of oral intake, which can lead to electrolyte imbalances and compromised renal function. Administering IV fluids helps maintain hydration, support renal function, and prevent complications. Administering antiemetics (choice A) can help alleviate nausea but does not address the underlying issue of dehydration. Nebulized bronchodilators (choice C) are not indicated for nausea related to chemotherapy. Monitoring vital signs (choice D) is important but not the priority intervention in this case where hydration is the main concern.
Question 3 of 5
Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Reduced excursion. When assessing a patient with COPD using the illustrated technique, reduced diaphragmatic excursion is a key finding. This is because in COPD, the lungs become hyperinflated due to air trapping, which limits the ability of the diaphragm to descend fully during inspiration and restricts its movement. This results in reduced diaphragmatic excursion, a common finding in patients with COPD. Option A) Hyperresonance is incorrect because it is commonly associated with conditions like emphysema, where there is increased air in the lungs causing a hyperresonant sound upon percussion. Option B) Tripod positioning is incorrect as it is a compensatory mechanism seen in patients with COPD to help improve breathing efficiency by stabilizing the upper body and allowing better use of respiratory muscles. Option D) Accessory muscle use is incorrect as it is also a compensatory mechanism seen in COPD, where patients may use additional muscles like the sternocleidomastoid or scalene muscles to aid in respiration due to the increased work of breathing. Educationally, understanding these assessment findings in patients with COPD is crucial for nurses to provide appropriate care and interventions. Recognizing reduced diaphragmatic excursion can guide nursing interventions such as breathing exercises, positioning techniques, and respiratory treatments to optimize oxygenation and respiratory function in patients with COPD. This knowledge helps nurses provide holistic care and improve patient outcomes in clinical practice.
Question 4 of 5
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6°F (38.7°C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Obtain a throat culture. Explanation: When a patient presents with symptoms such as anterior cervical lymph node swelling, a fever, and yellow patches on the tonsils, it indicates a high suspicion of a bacterial infection, such as streptococcal pharyngitis (strep throat). A throat culture is necessary to confirm the presence of the bacteria causing the infection. This is crucial for accurate diagnosis and appropriate treatment with antibiotics, as bacterial infections require specific treatment to prevent complications and spread of the infection. Why the other options are incorrect: B) Administering an antipyretic would help reduce the fever but does not address the underlying cause of the symptoms, which is a bacterial infection. Symptomatic relief alone without treating the infection is not sufficient. C) Teaching the patient to gargle with warm salt water may provide some relief for a sore throat but does not address the need for a definitive diagnosis and treatment of a bacterial infection. D) Applying a cool compress to the neck may help reduce discomfort but does not address the need for further assessment and treatment of a bacterial infection causing the symptoms. Educational context: Understanding the rationale behind choosing the correct action in this scenario is essential for nurses to provide safe and effective patient care. By recognizing the signs and symptoms of a bacterial infection in a patient with a sore throat, nurses can demonstrate critical thinking skills in assessing and managing patients with respiratory conditions. This knowledge empowers nurses to advocate for appropriate diagnostic testing and treatment to ensure positive patient outcomes and prevent complications associated with untreated bacterial infections.
Question 5 of 5
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
Correct Answer: D
Rationale: In this scenario, the correct intervention is D) Chest tube connected to suction. This is the most appropriate action because the absent breath sounds and tachycardia indicate a potential pneumothorax, which is a life-threatening condition where air accumulates in the pleural space, causing lung collapse. A chest tube connected to suction is necessary to re-expand the lung by removing the trapped air or fluid. Option A) Emergency pericardiocentesis is incorrect because this procedure involves draining fluid from the pericardial sac around the heart, which is not indicated in this case of suspected pneumothorax. Option B) Stabilization of the chest wall is incorrect as the primary issue here is not related to chest wall stability but rather to the presence of air in the pleural space. Option C) Bronchodilator administration is also incorrect because a bronchodilator is used to treat conditions like asthma or chronic obstructive pulmonary disease (COPD), not for pneumothorax. Educationally, understanding the rationale behind choosing the correct intervention is crucial for nurses to provide safe and effective care in emergency situations. Recognizing the signs and symptoms of pneumothorax and knowing the appropriate intervention of chest tube insertion can potentially save a patient's life by restoring lung function and preventing further complications. This case highlights the importance of quick and accurate assessment skills in emergency care settings.