ATI RN
Oxygenation Nursing Practice Questions 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 intervention?
Correct Answer: B
Rationale: The correct answer is B: Administer IV fluids. The priority intervention for a patient with hypertension experiencing chest pain is to ensure adequate perfusion to vital organs. Administering IV fluids helps improve blood flow, stabilize blood pressure, and support cardiac function. This intervention is crucial in managing chest pain and preventing potential complications. Administering nitroglycerin (choice A) is important for chest pain relief but may cause a drop in blood pressure, which can be risky in patients with hypertension. Administering aspirin (choice C) is important for antiplatelet effects but does not address the immediate need for perfusion. Administering morphine (choice D) is used for pain relief but may mask symptoms and delay necessary interventions.
Question 2 of 5
After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
Correct Answer: A
Rationale: In this scenario, option A, "Weak cough effort," best supports the nursing diagnosis of ineffective airway clearance in a patient with pneumonia. A weak cough effort can impede the effective removal of secretions from the airway, leading to potential airway obstruction and inadequate oxygenation. Option B, "Profuse green sputum," is often associated with infection but does not directly indicate ineffective airway clearance. Option C, "Respiratory rate of 28 breaths/minute," may suggest increased work of breathing but does not specifically address the clearance of airway secretions. Option D, "Resting pulse oximetry (SpO₂) of 85%," indicates hypoxemia but does not directly relate to the ability to clear the airway. Educationally, understanding the significance of a weak cough effort in relation to airway clearance is crucial for nurses caring for patients with respiratory conditions like pneumonia. Recognizing this sign can prompt appropriate interventions to promote effective airway clearance, such as positioning, chest physiotherapy, or nebulization. This rationale highlights the importance of clinical assessment skills and critical thinking in nursing practice to provide optimal patient care.
Question 3 of 5
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care?
Correct Answer: C
Rationale: Educational Rationale: The correct answer is option C) Frequent use of an incentive spirometer. The rationale behind this is that after a pneumonectomy (surgical removal of a lung), it is crucial for the patient to engage in deep breathing exercises to prevent complications such as atelectasis (lung collapse) and promote lung expansion. Incentive spirometry helps the patient take slow, deep breaths to keep the air sacs in the lungs open and prevent mucus buildup, aiding in the recovery process. Option A) Bed rest for the first 24 hours is incorrect because early ambulation and movement are crucial in preventing postoperative complications like blood clots and pneumonia. Prolonged bed rest can lead to decreased lung expansion and increase the risk of respiratory issues. Option B) Positioning only on the right side is incorrect as it restricts movement and may not be comfortable for the patient. Positioning changes are necessary postoperatively to prevent complications such as pressure ulcers and promote lung expansion. Option D) Chest tube placement to continuous suction is also incorrect because after a pneumonectomy, chest tubes are not typically used, as the remaining lung is usually able to compensate for the loss of the removed lung. Continuous suction can lead to excessive drainage and increase the risk of complications such as infection. Educationally, understanding the rationale behind postoperative care after a pneumonectomy is essential for nurses to provide safe and effective care to their patients. By knowing the correct interventions, nurses can promote optimal recovery and prevent complications, ultimately improving patient outcomes and quality of care. It is crucial for nurses to stay updated on evidence-based practices to deliver the best possible care to patients undergoing complex procedures like pneumonectomy.
Question 4 of 5
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
Correct Answer: A
Rationale: The correct answer is A) Document the amount of drainage every 8 hours. This task can be delegated to the unlicensed assistive personnel (UAP) because it is a routine, non-invasive activity that does not require clinical judgment. Documenting drainage volume is essential to monitor the patient's condition and ensure appropriate management of the chest tube. Option B) Obtain samples of drainage for culture requires a level of skill and understanding of the rationale behind collecting samples for culture, which falls outside the scope of practice for UAPs. Option C) Assessing the patient's pain level associated with the chest tube involves subjective interpretation and critical thinking, which are nursing responsibilities that should not be delegated to UAPs. Option D) Checking the water-seal chamber for the correct fluid level involves interpreting the functioning of the chest tube system and ensuring its proper operation, which requires nursing knowledge and clinical judgment. Educationally, it is vital for nurses to understand the scope of practice for UAPs and to delegate tasks appropriately based on the complexity and level of skill required. By knowing which tasks can be safely delegated, nurses can optimize patient care while allowing UAPs to contribute to the healthcare team effectively.
Question 5 of 5
A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, 'I wish I were dead! I'm just a burden on everybody.' Based on this information, which nursing diagnosis is most appropriate?
Correct Answer: B
Rationale: In this scenario, option B, "Chronic low self-esteem related to physical dependence," is the most appropriate nursing diagnosis. The patient's statement of feeling like a burden and expressing a desire to be dead indicates a deep sense of worthlessness linked to their physical dependence due to COPD. This reflects a chronic issue with self-esteem that needs to be addressed. Option A, "Complicated grieving related to expectation of death," is incorrect because the patient is expressing feelings of worthlessness and burden, not necessarily grieving or accepting the expectation of death. Option C, "Ineffective coping related to unknown outcome of illness," is incorrect as the patient's statement is more about self-perception and feelings of being a burden rather than coping with the unknown outcome of the illness. Option D, "Deficient knowledge related to lack of education about COPD," is not the most appropriate diagnosis in this situation as the patient's statement does not directly indicate a lack of knowledge about COPD. Educationally, it is important for nurses to understand how to interpret patients' statements and behaviors to identify underlying nursing diagnoses accurately. This case highlights the significance of assessing patients' emotional well-being and self-perception in the context of their illness to provide appropriate care and support. Addressing issues of self-esteem and feelings of worthlessness is crucial in promoting the overall well-being of patients with chronic conditions like COPD.