ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 of 5
A nurse is caring for a postoperative patient who is complaining of severe pain. What is the priority action?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Administer pain medications. The priority in this situation is to address the patient's severe pain to ensure their comfort and well-being. Pain management is a crucial aspect of postoperative care as uncontrolled pain can lead to various complications and adversely affect the patient's recovery process. Option B) Administer subcutaneous insulin is incorrect as it is not the priority at this moment. While managing blood glucose levels is important in a postoperative patient, addressing severe pain takes precedence in this case. Option C) Administer pain relief is vague and does not specify a concrete action. Administering pain relief can encompass various interventions, but the priority is to provide pain medications promptly in this immediate situation. Option D) Monitor the patient's blood glucose levels is also not the priority when the patient is experiencing severe pain. While monitoring blood glucose levels is essential, it can be done after addressing the immediate concern of pain management. From an educational perspective, it is important for nurses to prioritize patient care based on the principle of addressing the most critical needs first. Understanding the hierarchy of needs helps nurses make informed decisions in providing safe and effective care to their patients. Prompt pain management is crucial in enhancing patient comfort, promoting recovery, and ensuring overall patient satisfaction.
Question 2 of 5
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). What is the priority action?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Administer pain relief. The priority action for a patient with COPD experiencing pain is to provide pain relief to alleviate their discomfort. Pain can exacerbate respiratory distress in patients with COPD, leading to increased work of breathing and potential complications. Addressing pain promptly not only improves the patient's comfort but also supports their respiratory function. Option A) Administer oxygen therapy may seem like a logical choice, but in this case, addressing the patient's pain takes precedence over oxygen therapy as pain can worsen respiratory distress. Option B) Administer morphine for pain relief is incorrect as it duplicates the correct answer but adds a specific medication. Providing pain relief without specifying a medication allows for flexibility in choosing the most appropriate pain relief intervention based on the patient's individual needs and condition. Option D) Administer insulin therapy is irrelevant to the patient's immediate needs in managing COPD and is not a priority action in this situation. Educationally, understanding the priority of interventions in managing COPD is crucial for nurses caring for these patients. Pain management plays a significant role in improving patient outcomes and should be promptly addressed to enhance patient comfort and support respiratory function. Nurses must prioritize interventions based on the patient's condition and individual needs to provide safe and effective care.
Question 3 of 5
A nurse is caring for a patient with a history of diabetes. The patient is complaining of blurry vision. What is the priority action?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Administer insulin. The priority action is to address the patient's complaint of blurry vision, which can be a sign of hyperglycemia in a patient with diabetes. Administering insulin is crucial to lower the elevated blood glucose levels that may be causing the blurry vision and prevent potential complications like diabetic retinopathy. Option A) Monitor blood glucose levels is not the priority in this situation because the patient is already experiencing symptoms of hyperglycemia, and prompt intervention is needed. Option B) Administer a nebulizer is not relevant to the patient's complaint of blurry vision, which is likely related to the uncontrolled blood glucose levels. Option D) Monitor vital signs is important but not the immediate priority when the patient is experiencing a symptom that indicates a potential diabetic emergency. Educationally, this question highlights the importance of recognizing early signs of hyperglycemia in patients with diabetes and the need for prompt intervention to prevent complications. Understanding the link between diabetes, hyperglycemia, and ocular complications is crucial for nurses to provide safe and effective care for diabetic patients.
Question 4 of 5
A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?
Correct Answer: A
Rationale: The correct answer is A) Allergy to shellfish. Communicating this information to the health care provider is a priority before the CT scan because the patient may have a contrast dye allergy, often derived from shellfish, which could lead to a severe allergic reaction during the scan. This crucial information allows the provider to take necessary precautions to prevent a potentially life-threatening situation. Option B) Apical pulse of 104 is not the priority as it may be within normal limits considering the patient's acute dyspnea. Option C) Respiratory rate of 30 is also important but not as critical as the allergy information. Option D) O₂ saturation of 90% is concerning but may be due to the underlying dyspnea, whereas the allergy poses an immediate risk. Educationally, this question highlights the importance of thorough assessment and communication of critical information to ensure patient safety during diagnostic procedures. It emphasizes the significance of recognizing and prioritizing patient data to guide appropriate nursing interventions and collaborative care with healthcare providers.
Question 5 of 5
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A) A patient who is complaining of a sore throat and has a muffled voice should be assessed first in the ENT clinic. This patient's symptoms could indicate a potential airway obstruction, such as an abscess or swelling in the throat, which could rapidly progress to a life-threatening situation. Prompt assessment and intervention are crucial in this scenario. Option B) is incorrect because while the positive rapid strep test indicates a bacterial infection, it does not pose an immediate threat to the patient's airway or respiratory status, unlike a potential airway obstruction. Option C) is incorrect as severe fatigue in a patient receiving radiation for throat cancer is concerning but does not pose an immediate risk to the patient's airway or respiratory status. Option D) is incorrect because while redness and inflammation around a stoma in a patient with a laryngectomy are concerning for infection, it is not as urgent as the potential airway compromise presented by the symptoms in option A. Educationally, this question highlights the importance of prioritizing patient care based on the urgency of the situation, particularly in an ENT setting where respiratory compromise can quickly become life-threatening. Nurses must be able to quickly assess and prioritize patients based on their clinical presentation to ensure the best outcomes for their patients.