ATI RN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
A nurse is caring for a patient with chronic kidney disease (CKD). What is the priority action?
Correct Answer: D
Rationale: The correct answer is D: Administer IV morphine. In CKD, pain management is crucial due to complications like uremic neuropathy. Morphine is a common analgesic used in CKD patients. Administering diuretics (A) can worsen kidney function. Administering IV fluids (B) may further stress the kidneys. Administering corticosteroids (C) can exacerbate fluid retention and electrolyte imbalances in CKD patients.
Question 2 of 5
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure?
Correct Answer: C
Rationale: The correct answer is C) Keep the patient NPO until the gag reflex returns. This intervention is crucial post-bronchoscopy with biopsy to prevent aspiration due to the effects of local anesthesia. Maintaining NPO status ensures that the patient's airway is protected until their ability to swallow safely is confirmed by the return of the gag reflex. Option A, encouraging the patient to drink clear liquids, is incorrect because introducing fluids too soon post-procedure can lead to aspiration. Option B, placing the patient on bed rest for at least 4 hours, is not the immediate priority after a bronchoscopy with biopsy. Option D, maintaining the head of the bed elevated 90 degrees, is important for respiratory support but not the first priority in this scenario. Educationally, understanding the rationale behind post-bronchoscopy care is essential for nurses caring for patients undergoing this procedure. Emphasizing the importance of airway protection, the prevention of aspiration, and the significance of waiting for the return of the gag reflex can help nurses provide safe and effective care in post-bronchoscopy situations.
Question 3 of 5
Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx?
Correct Answer: A
Rationale: The correct answer is option A: "I will need to buy a water bottle to carry with me." This statement indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx because radiation therapy can lead to dry mouth as a common side effect. Carrying a water bottle helps the patient stay hydrated and manage dry mouth effectively. Option B: "I should not use any lotions on my neck and throat." This statement is incorrect because using water-based lotions or moisturizers on the neck and throat can actually help soothe any skin irritation that may occur due to radiation therapy. Therefore, this statement does not reflect effective teaching for a patient undergoing laryngeal radiation therapy. Option C: "Until the radiation is complete, I may have diarrhea." This statement is unrelated to the side effects of radiation therapy for the larynx. Diarrhea is not a typical side effect of radiation therapy targeting the larynx, so this option is incorrect in this context. Option D: "Alcohol-based mouthwashes will help clean my mouth." This statement is incorrect because alcohol-based mouthwashes can actually exacerbate dry mouth, which is a common side effect of radiation therapy to the larynx. Therefore, recommending alcohol-based mouthwashes would not be considered effective teaching for a patient undergoing this treatment. In an educational context, it is crucial for healthcare providers to provide accurate and relevant information to patients undergoing radiation therapy. Effective patient education helps patients understand the potential side effects of their treatment and how to manage them appropriately. Encouraging patients to stay hydrated and carry a water bottle is a practical and beneficial strategy for managing dry mouth during laryngeal radiation therapy, making option A the most appropriate choice in this scenario.
Question 4 of 5
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
Correct Answer: C
Rationale: The correct answer is C) Teach the patient about providing specimens for 3 consecutive days. This is the appropriate action because diagnosing tuberculosis (TB) requires sputum samples for acid-fast bacilli (AFB) testing over multiple days to confirm the presence of active infection. TB diagnosis is not solely based on a positive skin test or a single sputum sample but requires consistent collection to increase the accuracy of results. Option A, teaching about the reason for blood tests, is incorrect as bacteriologic testing for TB involves sputum samples, not blood tests. Option B, scheduling a chest x-ray, is not the immediate next step for confirming TB diagnosis, as sputum testing is the primary method for diagnosing TB. Option D, instructing the patient to collect several separate sputum specimens today, is not ideal since collecting samples over consecutive days is important to increase the likelihood of detecting the TB bacteria if present. In an educational context, understanding the rationale behind the need for multiple sputum samples in diagnosing TB is crucial for nursing students. It emphasizes the importance of following evidence-based practices and diagnostic protocols to ensure accurate diagnosis and appropriate treatment for patients. By explaining the significance of this process, students can grasp the complexities of TB diagnosis and provide optimal care to patients undergoing diagnostic testing for infectious diseases.
Question 5 of 5
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
Correct Answer: A
Rationale: In this scenario, the correct answer is option A: O₂ saturation is 88%. This is the priority assessment to communicate to the healthcare provider because it indicates hypoxemia, which is a serious condition post-thoracentesis that requires immediate intervention to ensure adequate oxygenation and prevent complications like respiratory distress or organ damage. Option B, blood pressure of 155/90 mm Hg, though elevated, is not as immediately life-threatening as hypoxemia in this context. While hypertension should be monitored and managed, oxygenation takes precedence due to its critical role in sustaining life. Option C, pain level of 5 with a deep breath, is important to address for patient comfort and to monitor for potential complications like pneumothorax. However, in this case, the oxygenation status is a more urgent concern that requires immediate attention. Option D, a respiratory rate of 24 breaths/minute when lying flat, is concerning but not as critical as hypoxemia. Respiratory rate changes may be expected post-thoracentesis due to pain or anxiety, but addressing oxygen saturation is paramount to prevent respiratory compromise. Educationally, this question highlights the importance of prioritizing assessments based on clinical urgency. It underscores the significance of promptly recognizing and addressing hypoxemia to prevent serious complications and optimize patient outcomes in post-thoracentesis care.