ATI RN
NCLEX Questions on Oxygenation and Perfusion Questions
Question 1 of 5
A nurse is teaching a client who has a tracheostomy about suctioning. Which of the following instructions should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Suction the tracheostomy for 15 seconds at a time. This instruction is appropriate because prolonged suctioning can lead to tissue damage and hypoxia. Here's a step-by-step rationale: 1. Suctioning for 15 seconds helps prevent hypoxia and mucosal damage. 2. Longer suctioning time can cause trauma to the tracheal mucosa. 3. Adequate oxygenation is crucial during suctioning. 4. Regular breaks between suction passes allow for reoxygenation. Other choices are incorrect: B: Sterile water is not recommended for cleaning the catheter as it may introduce infection. C: Inserting the catheter until resistance is met can cause damage to the trachea. D: Suctioning every hour is not necessary and can lead to potential harm.
Question 2 of 5
The nurse is caring for a client with chronic bronchitis who has a productive cough. What intervention should the nurse implement to promote effective airway clearance?
Correct Answer: A
Rationale: Correct Answer: A: Encourage fluid intake of at least 2 liters per day. Rationale: 1. Adequate hydration helps to keep respiratory secretions thin and easier to expectorate. 2. Increased fluid intake helps to prevent dehydration, which can thicken secretions and worsen cough. 3. Hydration is essential for overall health and helps to maintain optimal pulmonary function. Summary: B: Limiting activity may lead to decreased respiratory effort and impaired airway clearance. C: Cough suppressants can hinder the body's natural mechanism to clear secretions. D: Providing supplemental oxygen may help with oxygenation but does not directly promote effective airway clearance.
Question 3 of 5
The nurse is teaching a client with a new diagnosis of COPD about pursed-lip breathing. What is the primary benefit of this technique?
Correct Answer: B
Rationale: The correct answer is B: Reduces airway resistance. Pursed-lip breathing helps to slow down the exhalation process, which in turn reduces the amount of air trapped in the lungs and decreases airway resistance. This technique promotes better oxygen exchange and helps the client breathe more efficiently. A: Increases oxygen intake - Pursed-lip breathing does not directly increase oxygen intake but rather improves the efficiency of oxygen exchange by reducing airway resistance. C: Slows the respiratory rate - While pursed-lip breathing may slow down the breathing pattern, the primary benefit is the reduction of airway resistance, not solely slowing the respiratory rate. D: Prevents hyperventilation - Pursed-lip breathing can help prevent hyperventilation by promoting more controlled breathing, but the primary benefit is the reduction of airway resistance for clients with COPD.
Question 4 of 5
The nurse is assessing a client with a chest tube. Which finding requires immediate action?
Correct Answer: A
Rationale: The correct answer is A because continuous bubbling in the water seal chamber indicates an air leak in the chest tube system, which can lead to pneumothorax. Immediate action is needed to prevent respiratory compromise. Choice B is incorrect because drainage of 50 mL in the past hour is within normal limits for a chest tube output. Choice C, tidaling in the water seal chamber, is a normal finding indicating proper functioning of the chest tube system. Choice D is incorrect because although the chest tube dressing intact with no drainage is a good sign, it does not require immediate action compared to an air leak.
Question 5 of 5
The nurse is teaching a client with obstructive sleep apnea about lifestyle changes. Which recommendation is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: Lose weight to reduce airway obstruction. This recommendation is most appropriate as excess weight can contribute to airway obstruction in obstructive sleep apnea. Losing weight can help reduce the amount of fatty tissue around the airway, improving airflow during sleep. A: Sleeping in a supine position may worsen obstructive sleep apnea by causing the tongue and soft tissues to block the airway. B: Limiting fluid intake in the evening may help reduce nighttime trips to the bathroom but does not directly address the underlying cause of obstructive sleep apnea. D: Avoiding the use of CPAP even if symptoms improve is not recommended as CPAP therapy is an effective treatment for obstructive sleep apnea and helps maintain open airways during sleep.