ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
A nurse is caring for a patient with asthma who is experiencing shortness of breath. What is the priority nursing intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to open the airways quickly, providing immediate relief for the patient's shortness of breath in an acute asthma attack. This intervention addresses the patient's current distress and helps improve oxygenation. Administering corticosteroids (choice B) is important for long-term management but not the priority in an acute situation. Monitoring vital signs (choice C) is essential but not the immediate priority when the patient is in respiratory distress. Administering insulin (choice D) is not indicated for asthma and would not address the patient's shortness of breath.
Question 2 of 5
Teach the patient about the use of expectorants.
Correct Answer: C
Rationale: The correct option, C) Teach the patient to avoid nonsteroidal anti-inflammatory drugs (NSAIDs), is the most appropriate choice when teaching a patient about the use of expectorants. This is because NSAIDs can actually worsen respiratory conditions by causing bronchoconstriction and inhibiting the body's ability to clear secretions. It is crucial for patients using expectorants to be aware of this potential interaction to optimize their respiratory health. Option A) Use a swab to obtain a sample for a rapid strep antigen test, is incorrect as it is not related to teaching about expectorants. Rapid strep tests are used to diagnose streptococcal pharyngitis, which is unrelated to expectorant use. Option B) Discuss the need to rinse the mouth out after using any inhalers, while important for preventing oral thrush with inhaled corticosteroids, is not directly related to teaching about expectorants and their mechanisms of action in loosening mucus. In an educational context, understanding the rationale behind teaching patients about the appropriate use of expectorants is essential for healthcare providers. By providing accurate information and guidance on medication use, patients can better manage their respiratory conditions and improve their overall health outcomes. It is important to emphasize the specific instructions and precautions associated with expectorants to ensure patient safety and effectiveness of treatment.
Question 3 of 5
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is to continue to monitor the collection device (Option B) because continuous bubbling in the suction-control chamber of a chest tube collection device is expected when the system is functioning properly. This bubbling indicates that suction is being applied and that the chest tube is effectively draining fluid or air from the patient's pleural space. It is essential for the nurse to understand the normal functioning of the chest tube drainage system to differentiate between expected and concerning findings. Adjusting the dial on the wall regulator (Option A) is not necessary in this situation because the bubbling indicates that the suction is working correctly. Documenting the presence of a large air leak (Option C) may lead to unnecessary alarm if the bubbling is due to the expected suction. Notifying the surgeon of a possible pneumothorax (Option D) is premature without further assessment or evidence of a complication. Educationally, understanding the rationale behind the expected findings in chest tube management is crucial for nurses caring for patients with thoracic surgeries. This knowledge ensures appropriate and timely interventions, prevents unnecessary actions that may disrupt patient care, and promotes safe and effective nursing practice in managing chest tubes and drainage systems. Nurses must be equipped with the knowledge and critical thinking skills to assess, interpret, and respond to chest tube drainage system findings accurately to provide optimal care for their patients.
Question 4 of 5
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
Correct Answer: D
Rationale: In this scenario, option D is the correct answer because using the incentive spirometer every hour or two during the day helps prevent atelectasis and pneumonia, which are common complications associated with rib fractures. The incentive spirometer encourages deep breathing, improving lung function and preventing respiratory complications. Option A is incorrect because while a rib binder can provide support and comfort, it does not directly address the respiratory complications that can arise from rib fractures. Option B is incorrect because taking shallow breaths can lead to atelectasis and impaired lung function. Option C is incorrect because pain management should be consistent and not restricted to bedtime only. Effective pain control is crucial for promoting deep breathing, coughing, and mobility, all of which are essential for preventing respiratory complications in patients with rib fractures. Educationally, it is important for patients to understand the rationale behind using the incentive spirometer to prevent respiratory complications. By teaching patients the importance of deep breathing exercises and lung expansion techniques, nurses empower them to actively participate in their recovery and reduce the risk of complications. This educational context helps patients make informed decisions about their care and promotes better outcomes.
Question 5 of 5
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?
Correct Answer: D
Rationale: The correct answer, option D, is the most appropriate instruction for the older adult with severe COPD to increase activity tolerance at home. Walking for 15 to 20 minutes a day at least 3 times a week promotes gradual and safe progression in physical activity, helping to improve endurance without overexertion. This recommendation aligns with the principles of pulmonary rehabilitation for COPD patients, which emphasize regular, moderate exercise to enhance functional capacity and reduce symptoms. Option A is incorrect because stopping exercise when feeling short of breath may lead to avoidance of physical activity, hindering progress in improving activity tolerance. Option B is incorrect as exceeding a pulse rate of 130 beats/minute can indicate overexertion, which is not safe for individuals with COPD and can worsen symptoms. Option C is also incorrect as limiting exercise to activities of daily living may not provide enough physical activity to effectively increase activity tolerance in this population. Educationally, it is crucial for nurses to understand the principles of exercise prescription for patients with COPD to optimize their respiratory function and quality of life. By providing tailored instructions like walking for 15 to 20 minutes a day, nurses can empower patients to engage in safe and effective physical activity, promoting better management of their condition and overall well-being.