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: Bleeding is a critical postoperative risk; monitoring the incision is the priority in the first 24 hours.
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: Non-adherence is a common reason for persistent positive smears; assessing compliance is the first step before escalating treatment.
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: Sudden shortness of breath in a bedridden patient suggests a possible pulmonary embolism, a life-threatening emergency requiring immediate assessment.
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: Pursed-lip breathing helps manage anxiety-related dyspnea by prolonging exhalation and reducing air trapping.