ATI RN
Fundamentals of Nursing Oxygenation Practice Questions Questions
Question 1 of 5
A nurse is caring for a patient with a history of asthma who is experiencing wheezing. What is the priority action?
Correct Answer: C
Rationale: The correct answer is C: Administer insulin therapy. The priority action in this scenario is to address the patient's wheezing due to asthma. Administering insulin therapy would be incorrect as it is not relevant to the patient's current condition. Administering insulin for elevated blood glucose levels would also be incorrect as the patient's primary issue is wheezing, not high blood sugar. Administering pain medication is not the priority as it does not address the underlying cause of wheezing in a patient with asthma. Therefore, the priority action is to provide appropriate asthma treatment to alleviate the wheezing and ensure the patient's respiratory status is stabilized.
Question 2 of 5
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated?
Correct Answer: A
Rationale: The correct answer is A) Use a hand-held manometer to measure cuff pressure. This action is crucial because it allows the nurse to ensure that the cuff pressure is within safe limits. Proper cuff inflation prevents complications such as tracheal damage, aspiration, and air leakage, which are common risks associated with mechanical ventilation and tracheostomy tubes. Option B is incorrect because relying solely on the health record for prescribed cuff pressure may not account for individual variations in patient anatomy and needs. It is essential to measure the cuff pressure directly to ensure it is appropriate for the specific patient. Option C is incorrect as suctioning through a fenestrated inner cannula is unrelated to assessing cuff inflation. This action addresses airway clearance and secretion management, not cuff pressure monitoring. Option D is incorrect because inserting the decannulation plug before removing the non-fenestrated inner cannula is a step in tracheostomy care but does not assess cuff inflation. It is essential to prioritize measuring cuff pressure to ensure patient safety during mechanical ventilation. In an educational context, understanding the importance of monitoring cuff pressure in mechanically ventilated patients with tracheostomy tubes is fundamental for nurses providing respiratory care. Mastery of this skill is vital to prevent complications and ensure optimal patient outcomes. Regular training and competency assessments on cuff pressure monitoring using a manometer should be incorporated into nursing education programs to enhance patient safety and quality of care.
Question 3 of 5
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
Correct Answer: C
Rationale: In this scenario, option C is the correct answer because a normal white blood cell (WBC) count of 9000/μL indicates that the infection is resolving, which is a key indicator of effective antibiotic treatment. Elevated WBC counts are typically seen in the presence of an infection as the body tries to fight off the invading pathogens. When the infection starts to resolve, the WBC count returns to normal levels. Option A is incorrect because bronchial breath sounds at the right base suggest consolidation and are indicative of pneumonia, not effective treatment. Option B is incorrect as coughing up green mucus can indicate the presence of infection, not necessarily the effectiveness of treatment. Option D is also incorrect as increased tactile fremitus over the right chest can indicate consolidation and is not a reliable indicator of treatment effectiveness. Educationally, understanding the importance of monitoring WBC counts in assessing the effectiveness of antibiotic treatment in cases of pneumonia is crucial for nurses. This knowledge helps in making informed clinical decisions and evaluating patient progress accurately. It emphasizes the significance of using objective data to determine treatment outcomes and guides nursing interventions for optimal patient care.
Question 4 of 5
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B) Blood cultures from two sites. In a patient with probable bacterial pneumonia and sepsis, obtaining blood cultures is the priority as it helps in identifying the causative organism accurately. This information is crucial for selecting the most effective antibiotic therapy, thereby improving patient outcomes. Option A, Chest x-ray via stretcher, is important for diagnosing pneumonia but does not address the immediate need for identifying the causative organism. Option C, administering Ciprofloxacin IV, is essential for treating the infection but should be based on culture results. Option D, administering Acetaminophen rectal suppository, addresses fever management but does not address the underlying infection. In an educational context, understanding the rationale behind prioritizing interventions in a patient with suspected sepsis is vital for nursing practice. By emphasizing the importance of obtaining blood cultures early in such cases, nurses can ensure timely and appropriate treatment, ultimately improving patient care and safety. This question reinforces the principle of evidence-based practice and the significance of accurate diagnostic testing in guiding clinical decision-making.
Question 5 of 5
A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure?
Correct Answer: C
Rationale: The correct answer is C) Withhold bronchodilators for 6 to 12 hours before the examination. This is the right action because bronchodilators can temporarily improve lung function, which would alter the spirometry results and provide an inaccurate assessment of the patient's baseline lung capacity. By withholding bronchodilators, the nurse ensures that the spirometry test reflects the true lung function of the patient without the effects of the medication. Option A is incorrect because giving the rescue medication immediately before testing can skew the results by artificially improving lung function. Option B is incorrect as administering oral corticosteroids 2 hours before the procedure may not have an immediate impact on lung function. Option D is also incorrect because there is no need for the patient to be NPO for spirometry testing. In an educational context, it is essential for nurses to understand the importance of proper preparation for diagnostic procedures like spirometry to obtain accurate results. By knowing the effects of medications on test outcomes, nurses can ensure that patients receive the most reliable assessments of their respiratory status, leading to better clinical decision-making and patient care.