ATI LPN
Oxygenation NCLEX Questions Questions
Question 1 of 5
A nurse provides care for a client who has severe anemia and received a transfusion of packed RBCs. Which data indicates the goal of therapy has been met?
Correct Answer: A
Rationale: A hemoglobin of $12 \mathrm{~g} / \mathrm{dL}$ would indicate a therapeutic response to therapy. The expected pharmacologic action of packed RBCs is to increase the number of red blood cells and improve the hemoglobin. One indication for the administration of packed RBCs is severe symptomatic anemia (Hgb 6 to $10 \mathrm{~g} / \mathrm{dL}$ ).
Question 2 of 5
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?
Correct Answer: A
Rationale: Heat stroke is a medical emergency with elevated body temperature and organ dysfunction. Hypotension (A) occurs due to dehydration and vasodilation. Bradycardia (B) is incorrect as tachycardia is typical. Clammy skin (C) is more associated with heat exhaustion; heat stroke presents with hot dry skin. Bradypnea (D) is incorrect as tachypnea is common. Thus A is correct for heat stroke symptoms.
Question 3 of 5
The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?
Correct Answer: A
Rationale: Impaired Gas Exchange leads to chronic hypoxia prompting the body to increase erythrocyte production to enhance oxygen-carrying capacity resulting in increased hematocrit (A). Decreased BUN (B) relates to renal function not gas exchange. Increased blood sugar (C) is unrelated to oxygenation. Increased sedimentation rate (D) indicates inflammation but is nonspecific making A the supportive finding for this diagnosis.
Question 4 of 5
The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction?
Correct Answer: C
Rationale: Expectorating sputum allows the nurse to assess its quality (color consistency) and quantity (C) aiding in diagnosis and treatment evaluation. Sputum bacteria (A) are not inherently harmful if swallowed as stomach acid neutralizes them. Swallowing sputum (B) is not dangerous unless aspiration occurs which is unlikely if swallowing is intact (D). Thus C is the primary rationale for expectoration.
Question 5 of 5
The nurse who is assessing a clients chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?
Correct Answer: B
Rationale: Crackling (subcutaneous emphysema) indicates air in subcutaneous tissues possibly from a poor chest tube seal. Collaborating with the physician (B) is necessary to evaluate and address the issue as it may require intervention. Discontinuing suction (A) or removing the tube (C) is unsafe without physician guidance. Reinforcing the dressing (D) does not address the underlying cause making B the appropriate action.