ATI RN
NCLEX Questions on Oxygen Therapy Questions
Question 1 of 5
A nurse is caring for a patient with a history of myocardial infarction (MI). What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer aspirin. Aspirin is the priority intervention for a patient with a history of MI as it helps prevent further clot formation and reduces the risk of another cardiac event. Administering IV fluids (choices B and C) may be necessary depending on the patient's condition, but aspirin takes precedence to address the immediate cardiac issue. Administering morphine (choice D) is not the priority as it may mask symptoms and delay definitive treatment. Overall, the main goal in a patient with a history of MI is to prevent further clot formation and reduce the risk of complications, making aspirin the most appropriate intervention.
Question 2 of 5
The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?
Correct Answer: A
Rationale: The correct answer is A) "I must keep the stoma covered with an occlusive dressing." This statement indicates a need for additional instruction because an occlusive dressing could potentially block the stoma, leading to impaired breathing. Instead, a breathable cover should be used to protect the stoma without obstructing airflow. Option B) "I need to have smoke and carbon monoxide detectors installed" is a correct statement as these detectors are essential for the safety of a patient with a laryngectomy who may not be able to detect smoke or carbon monoxide by smell. Option C) "I can participate in my prior fitness activities except swimming" is also a correct statement because swimming can pose a risk of water entering the stoma and causing complications. Option D) "I should wear a Medic-Alert bracelet to identify me as a neck breather" is a correct statement as it is important for emergency responders to be aware of the patient's unique airway needs. Educationally, understanding the specific care needs of patients with a total laryngectomy is crucial for nurses. By providing accurate and clear discharge instructions, nurses can empower patients to manage their condition effectively at home and reduce the risk of complications. It is essential for nurses to impart this knowledge to ensure the safety and well-being of patients in their care.
Question 3 of 5
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A) Yellow-tinged sclera. This finding suggests jaundice, which can be a sign of hepatotoxicity, a potential adverse effect of anti-TB medications like isoniazid or rifampin. Jaundice indicates liver dysfunction, which can be serious and requires immediate medical attention to prevent further complications. Option B) Orange-colored sputum is not typically associated with TB medication side effects. It could be indicative of other conditions like chronic bronchitis or pneumonia, but it is not a direct concern related to TB drug therapy. Option C) Thickening of the fingernails is not a common side effect of TB medications and is more likely related to other factors such as aging, nutritional deficiencies, or fungal infections. It is not a critical finding that requires immediate notification of the healthcare provider. Option D) Difficulty hearing high-pitched voices is not a known side effect of TB medications. It could be related to age-related hearing loss or other ear-related issues but is not directly linked to the medication regimen for TB. Educationally, understanding the potential side effects of medications used in TB treatment is vital for nurses caring for patients with tuberculosis. Recognizing early signs of adverse reactions can prevent serious complications and improve patient outcomes. This question highlights the importance of thorough assessment skills and knowledge of medication side effects in providing safe and effective care to patients with TB.
Question 4 of 5
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
Correct Answer: D
Rationale: In this scenario, the correct answer is D. Lowering the head of the patient's bed to 15 degrees is not appropriate for a patient with right lower lobe pneumonia as it can increase the risk of aspiration and hinder lung expansion. This position can lead to pooling of secretions in the affected lobe, worsening the patient's condition. Option A is correct as it promotes mobility and prevents complications associated with immobility. Option B is also appropriate as splinting the chest during coughing can help reduce pain and prevent strain on the chest muscles, aiding in effective coughing and secretion clearance. Option C is acceptable as transferring the patient to a chair for meals promotes activity and aids in maintaining a sense of normalcy during the recovery process. Educationally, it is crucial to understand the rationale behind each action to provide safe and effective care to patients. Understanding the impact of positioning on respiratory conditions like pneumonia is essential for nursing practice. This question highlights the importance of maintaining an elevated position to facilitate lung expansion and prevent aspiration in patients with pneumonia, emphasizing the significance of evidence-based practice in nursing care.
Question 5 of 5
A young adult patient who denies any history of smoking is seen in the clinic with a new diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should plan to teach the patient about
Correct Answer: A
Rationale: The correct answer is option A, α⁴‚-antitrypsin testing, because in this scenario, the patient is a non-smoker who has been diagnosed with COPD. Non-smokers with COPD may have a genetic condition called α⁴‚-antitrypsin deficiency, which predisposes them to developing COPD. Testing for this deficiency is crucial in order to determine the underlying cause of the COPD in this patient and to provide appropriate management strategies. Option B, the use of the nicotine patch, is incorrect because this patient is a non-smoker, so nicotine replacement therapy would not be indicated for them. Option C, leukotriene modifiers, is also incorrect as these medications are primarily used in the treatment of asthma and allergic rhinitis, not COPD. Option D, continuous pulse oximetry, is not the most appropriate intervention in this case as it focuses on monitoring oxygen levels rather than addressing the underlying cause of the COPD in a non-smoking patient. In an educational context, it is important for nurses to understand the various causes of COPD, including genetic factors like α⁴‚-antitrypsin deficiency, in order to provide tailored and effective care for their patients. By recognizing the importance of genetic testing in non-smoking patients with COPD, nurses can ensure that appropriate interventions are implemented to manage the condition effectively.