ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 of 5
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care?
Correct Answer: A
Rationale: The correct answer is A) Assistance with activities of daily living. Rationale: 1. **Assisting with activities of daily living:** This intervention is appropriate because the client is experiencing dyspnea and exertional intolerance, indicating a need for conservation of energy. By assisting with activities of daily living, the nurse helps the client conserve energy and reduce the workload on their respiratory system, thereby reducing dyspnea. 2. **Physical therapy activities every day:** While physical therapy can be beneficial for improving strength and endurance, in this case, the client's current level of dyspnea suggests that intense physical therapy activities may exacerbate their symptoms and should be approached with caution. 3. **Oxygen therapy at 2 L per nasal cannula:** Oxygen therapy is not the first-line intervention for exertional dyspnea. While oxygen therapy may be indicated for clients with hypoxemia, it is important to assess the client's oxygen saturation levels before initiating oxygen therapy. 4. **Complete bedrest with frequent repositioning:** Bedrest is not typically indicated for clients with exertional dyspnea unless there are specific medical conditions necessitating it. Complete bedrest can lead to deconditioning and further exacerbate respiratory symptoms. Educational Context: Understanding interventions for clients experiencing dyspnea is crucial for nurses caring for individuals with respiratory issues. By selecting the appropriate intervention of assisting with activities of daily living, nurses can help clients manage their symptoms effectively and improve their quality of life. It is essential for nurses to prioritize interventions that promote energy conservation and reduce respiratory workload in clients with dyspnea.
Question 2 of 5
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?
Correct Answer: A
Rationale: The correct answer is A) "I can use a heating pad on my legs if it's set on low." This statement indicates a misunderstanding about self-management activities for a client with peripheral arterial disease (PAD) because applying heat can worsen the condition by dilating blood vessels and reducing blood flow, exacerbating symptoms. Option B) "I should not cross my legs when sitting or lying down" is correct as it promotes adequate circulation and helps prevent further complications in PAD. Option C) "I will go out and buy some warm, heavy socks to wear" is also a correct statement as keeping feet warm can help improve circulation in PAD. Option D) "It's going to be really hard but I will stop smoking" is an essential self-management activity for PAD as smoking cessation is crucial in preventing further damage to blood vessels and improving overall circulation. Educationally, this question highlights the importance of patient education in PAD management. It emphasizes the significance of lifestyle modifications and adherence to self-care practices to prevent disease progression and improve outcomes. Understanding misconceptions and correcting them is vital in promoting patient well-being and quality of life.
Question 3 of 5
The structure of the respiratory system that serves as the site of gas exchange is the
Correct Answer: C
Rationale: The correct answer is C) alveoli. Alveoli are tiny air sacs in the lungs where the exchange of oxygen and carbon dioxide occurs. They are surrounded by capillaries, allowing for efficient gas exchange to take place. The alveoli have thin walls, which are highly permeable to gases, facilitating the diffusion of oxygen into the bloodstream and carbon dioxide out of the bloodstream. Option A) Macrophage is incorrect because it is a type of immune cell found in the lungs that helps to clear out debris and pathogens but is not directly involved in gas exchange. Option B) Bronchi are the main passageways into the lungs, and while they help to transport air, they are not the specific site of gas exchange like the alveoli. Option D) Bronchioles are smaller airways that branch off from the bronchi and lead to the alveoli. They help to distribute air within the lungs but do not participate in gas exchange themselves. Understanding the structure and function of the respiratory system is crucial for healthcare professionals to provide effective care for patients with respiratory issues. By knowing that the alveoli are the site of gas exchange, nurses and other healthcare providers can assess and manage patients' oxygenation status more effectively. This knowledge is also essential for passing exams like the NCLEX, which assesses a nurse's ability to apply foundational knowledge to clinical scenarios.
Question 4 of 5
The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange?
Correct Answer: B
Rationale: In caring for a client with asthma to promote effective gas exchange, the most appropriate intervention is to teach pursed-lip breathing (Option B). Pursed-lip breathing helps improve oxygen saturation by slowing down the client's breathing rate, reducing the work of breathing, and promoting more effective gas exchange in the lungs. This technique also helps prevent bronchoconstriction and air trapping often seen in asthma exacerbations. Administering oxygen at 6 liters per minute (Option A) might seem beneficial, but in asthma, high-flow oxygen can sometimes worsen ventilation-perfusion mismatch, leading to hypoxemia. Restricting fluid intake (Option C) is not relevant to promoting effective gas exchange in asthma. Encouraging bed rest (Option D) can lead to deconditioning and worsen respiratory function. In an educational context, it is crucial for nurses to understand the pathophysiology of asthma and how different interventions can impact gas exchange. Teaching pursed-lip breathing empowers clients to actively participate in managing their condition and improves their overall respiratory function. Nurses should prioritize patient education and empower clients to take control of their health outcomes.
Question 5 of 5
The nurse observes a toddler, admitted with possible respiratory syncytial virus (RSV) bronchiolitis, grunting with expiration. Which action by the nurse is appropriate?
Correct Answer: C
Rationale: In this scenario, the appropriate action for the nurse is option C: Suction the airway to relieve the obstruction. Grunting with expiration in a toddler with possible RSV bronchiolitis indicates respiratory distress. Suctioning the airway helps to clear any secretions or mucus that may be obstructing the air passage, thereby improving the child's ability to breathe. Option A: Assisting the child to clear the nasal passages may not address the deeper airway obstruction that is causing the grunting. Option B: Limiting fluids is not relevant to addressing the respiratory distress in this situation. Option D: Laying the child on his back can worsen the respiratory distress by causing further obstruction. Placing the child in a semi-fowler's position or in a position that facilitates easier breathing would be more appropriate. Educational Context: Understanding the signs and symptoms of respiratory distress in pediatric patients is crucial for nurses, especially when dealing with conditions like RSV bronchiolitis. Proper airway management techniques, such as suctioning, can be life-saving in these situations. Nurses must be able to recognize respiratory distress in children and respond promptly and appropriately to ensure optimal patient outcomes.