ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Correct Answer: C Rationale: Administering 100% oxygen before suctioning helps prevent hypoxia during the procedure. - Choice A: Using clean technique is incorrect; sterile technique is required for tracheostomy care. - Choice B: Applying suction when inserting the catheter can cause trauma to the airway. - Choice D: Suctioning for 20 seconds each time can lead to hypoxia and should be done for no longer than 10-15 seconds.
Question 2 of 5
A client with pneumonia is placed on a fluid restriction of 1500 mL per day. How should the nurse manage the fluid intake?
Correct Answer: C
Rationale: The correct answer is C because allowing more fluids during the day helps prevent fluid overload and promotes optimal kidney function during waking hours. This approach also reduces the risk of nocturia. Providing fluids mainly at night (Choice A) can lead to disrupted sleep due to frequent bathroom trips. Dividing fluids equally across meals (Choice B) may not be appropriate as it could exceed the daily restriction. Limiting fluid intake to meals only (Choice D) may not provide enough hydration throughout the day, risking dehydration.
Question 3 of 5
A client with a pleural effusion is scheduled for a thoracentesis. What is the nurse's priority pre-procedure intervention?
Correct Answer: B
Rationale: The correct answer is B: Positioning the client sitting upright and leaning forward. This position helps to expose the area for the thoracentesis and prevents puncturing of the underlying structures. It also maximizes lung expansion, making the procedure safer and more effective. Administering analgesics (choice A) is important but not the priority. Ensuring informed consent (choice C) is important but can be done after positioning. Teaching deep breathing exercises (choice D) is also important but not the priority pre-procedure intervention.
Question 4 of 5
A client is experiencing respiratory acidosis. What is the nurse's priority intervention?
Correct Answer: D
Rationale: The correct answer is D. Positioning the client to promote lung expansion is the priority intervention for a client experiencing respiratory acidosis as it helps improve ventilation and oxygenation. This intervention helps optimize lung function and can aid in correcting the acidosis by increasing the efficiency of gas exchange. Administering a bronchodilator (A) may help with bronchoconstriction but is not the priority in this situation. Initiating deep breathing exercises (B) may be helpful in some cases but may not be appropriate for a client in respiratory distress. Providing supplemental oxygen (C) may help improve oxygenation, but without addressing the underlying cause of the acidosis, it may not fully resolve the issue.
Question 5 of 5
A nurse is assessing a client with suspected pulmonary embolism. Which clinical finding is most concerning?
Correct Answer: C
Rationale: The correct answer is C: Oxygen saturation of 87%. In pulmonary embolism, decreased oxygen saturation indicates impaired gas exchange due to reduced blood flow to the lungs. This is concerning as it can lead to hypoxemia and tissue damage. Respiratory rate (choice B) and heart rate (choice D) can be elevated in response to hypoxemia but are not as direct indicators of impaired gas exchange. Chest pain and hemoptysis (choice A) are common symptoms of pulmonary embolism but do not directly reflect the severity of oxygenation impairment.