ATI RN
NCLEX Questions Oxygen Therapy Questions
Question 1 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 action?
Correct Answer: B
Rationale: The correct answer is B: Administer insulin. In a patient with CKD experiencing fluid retention, insulin is the priority action. Insulin helps to regulate blood glucose levels, which can impact fluid balance in the body. High blood glucose levels can lead to osmotic diuresis, causing fluid retention. Administering insulin helps to lower blood glucose levels, which in turn can help reduce fluid retention. Choice A: Administer diuretics - While diuretics can help with fluid retention, in a patient with CKD, using diuretics without addressing the underlying cause (high blood glucose levels) can worsen kidney function. Choice C and D: Administer IV fluids - Administering more fluids would exacerbate the fluid retention issue in a patient with CKD. It is important to address the underlying cause of fluid retention first.
Question 2 of 5
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?
Correct Answer: A
Rationale: In the context of a patient who has undergone a total laryngectomy and radical neck dissection, monitoring the incision for bleeding is the priority nursing action in the first 24 hours post-surgery. This is crucial as these surgical procedures carry a high risk of bleeding due to the extensive tissue manipulation involved. Maintaining adequate IV fluid intake (Option B) is important for overall patient hydration and support, but it is not the priority in this immediate postoperative period where monitoring for complications takes precedence. Keeping the patient in semi-Fowler's position (Option C) is generally a good practice to promote respiratory function and reduce the risk of aspiration, but it is not the priority over monitoring for potential bleeding complications in the immediate postoperative phase. Teaching the patient to suction the tracheostomy (Option D) is not appropriate in the immediate postoperative period as the surgical site needs time to heal, and suctioning should be performed by trained healthcare professionals to prevent complications. Educationally, it is important for nurses to understand the critical nature of postoperative monitoring in high-risk surgeries like laryngectomy and neck dissection. This case highlights the significance of prioritizing assessments and interventions based on the specific needs of the patient to ensure optimal outcomes and prevent potential complications.
Question 3 of 5
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
Correct Answer: C
Rationale: The correct answer is C) Ask the patient whether medications have been taken as directed. Rationale: Correct Answer (C): This option is correct because non-adherence to the prescribed TB medication regimen is a common reason for persistent positive sputum smears. By asking the patient about their medication adherence, the nurse can identify if the treatment failure is due to improper drug intake. Addressing non-adherence is crucial before considering changes to the treatment plan. Incorrect Answers: A) Teaching about drug-resistant TB may be necessary if non-adherence is ruled out as the reason for treatment failure. However, it is not the immediate next step in this scenario. B) While directly observed therapy (DOT) can help monitor medication adherence, it is typically implemented after confirming non-adherence rather than as the initial action. D) Discussing the need for an injectable antibiotic with the healthcare provider is premature without first assessing the patient's adherence to the current oral medication regimen. Educational Context: Understanding the importance of patient compliance in TB treatment is vital for nurses caring for patients with this infectious disease. By prioritizing the assessment of medication adherence, nurses can address a common challenge in TB management and ensure better treatment outcomes. This scenario highlights the significance of thorough patient assessment and tailored interventions in managing TB effectively.
Question 4 of 5
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is option B - a 46-yr-old patient on bed rest complaining of sudden onset of shortness of breath. This patient should be assessed first because sudden shortness of breath in a patient at rest is a red flag for a potentially life-threatening condition like a pulmonary embolism. Immediate assessment is crucial to rule out this serious condition and initiate appropriate interventions promptly. Option A, the 23-yr-old patient with cystic fibrosis, is not the priority as pulmonary function testing can be rescheduled and does not indicate an acute change in the patient's condition requiring immediate attention. Option C, the 77-yr-old patient with TB needing medication, can wait a short time for the medications as missing the exact time by a few minutes is unlikely to have immediate adverse effects. Option D, the 35-yr-old patient with pneumonia and a low-grade fever, does not present with an acute, life-threatening symptom like sudden shortness of breath and can be assessed after the patient with the acute symptom. This scenario highlights the importance of prioritizing patient care based on the urgency and severity of the presenting symptoms. Nurses must be able to quickly prioritize and assess patients to provide timely and appropriate care, especially in emergency situations where swift action can make a significant difference in patient outcomes.
Question 5 of 5
The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?
Correct Answer: B
Rationale: The correct answer is B) Teach the patient how to use pursed-lip breathing. Pursed-lip breathing is a technique that can help patients with COPD manage their breathing patterns during episodes of anxiety. By prolonging exhalation, it helps to reduce air trapping and improve breathing efficiency, ultimately alleviating dyspnea associated with anxiety. This technique also promotes relaxation and decreases the work of breathing, making it an effective intervention for patients experiencing impaired breathing patterns due to anxiety. Option A) Titrate O₂ to keep saturation at least 90% is incorrect because while oxygen therapy is important in COPD patients, the question specifically addresses impaired breathing related to anxiety, not oxygen saturation. Option C) Discuss a high-protein, high-calorie diet with the patient is incorrect as it does not directly address the immediate need to manage breathing patterns during anxiety episodes. Option D) Suggest the use of over-the-counter sedative medications is incorrect because sedatives can depress the respiratory drive, potentially worsening respiratory issues in patients with COPD. Educationally, it is crucial for nurses to understand and implement non-pharmacological interventions like pursed-lip breathing to effectively manage patients with COPD experiencing anxiety-related breathing pattern disturbances. Teaching patients such techniques empowers them to take an active role in their care and can lead to improved outcomes and quality of life. This rationale emphasizes the importance of tailored nursing interventions in addressing holistic patient needs in respiratory care.