ATI RN
Oxygenation NCLEX Questions Questions
Question 1 of 5
A patient arrives in the emergency department with a stab wound to the chest. What action should the nurse take?
Correct Answer: D
Rationale: The correct answer is D because taping a nonporous dressing on three sides over the wound creates a flutter valve effect, allowing air to escape but not re-enter, preventing tension pneumothorax. Choice A (keeping the head of the bed flat) may worsen respiratory distress. Choice B (covering the wound tightly with an occlusive dressing) can lead to tension pneumothorax. Choice C (positioning the patient with the left chest dependent) is incorrect and may not address the immediate issue of air escaping from the wound.
Question 2 of 5
A patient with chronic obstructive pulmonary disease (COPD) is prescribed theophylline. Which finding would be most concerning?
Correct Answer: B
Rationale: The correct answer is B. A heart rate of 112 bpm is concerning in a patient taking theophylline because it can indicate theophylline toxicity, which can lead to serious cardiac arrhythmias. Theophylline has a narrow therapeutic index, and levels above 20 mcg/mL can be toxic. Nausea, vomiting, and mild hand tremors are common side effects of theophylline but are not typically indicative of toxicity. Monitoring the theophylline level is important, but a level of 15 mcg/mL alone does not indicate toxicity. In summary, the elevated heart rate is the most concerning finding as it suggests potential theophylline toxicity, while the other options are more commonly seen as side effects without indicating toxicity.
Question 3 of 5
The nurse prepares a patient for bronchoscopy. Which patient statement indicates the need for further pre-procedure teaching?
Correct Answer: C
Rationale: Correct Answer: C Rationale: 1. The patient statement "I can drive myself home after the procedure" indicates a lack of understanding of the sedative effects of the procedure. 2. Sedation is commonly used during bronchoscopy, impairing the patient's ability to drive safely. 3. Patients should arrange for someone to drive them home post-procedure to ensure their safety and comply with medical guidelines. Summary: A: Correct - Fasting before bronchoscopy is necessary to reduce the risk of aspiration. B: Incorrect - Throat discomfort is a common post-procedure symptom. D: Incorrect - Allergies to anesthesia should be reported for safety reasons.
Question 4 of 5
Which nursing intervention is most effective for a patient with thick respiratory secretions?
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink at least 2 liters of water daily. This intervention promotes hydration, which helps to liquefy thick respiratory secretions, making them easier to expectorate. Drinking adequate water also maintains mucous membrane hydration. Option B (mucolytics) may be prescribed but may not be as effective without sufficient hydration. Option C (suctioning) is invasive and should be done cautiously to prevent mucosal damage. Option D (chest physiotherapy) helps with secretion mobilization but may not be as directly effective as hydration in liquefying secretions. In summary, promoting hydration is the most effective and least invasive intervention for a patient with thick respiratory secretions.
Question 5 of 5
A patient with chronic bronchitis reports difficulty sleeping due to nighttime coughing. What is the nurse's best recommendation?
Correct Answer: D
Rationale: The correct answer is D: Sleep with an extra pillow to elevate the head. Elevating the head can help reduce nighttime coughing by promoting better drainage of mucus and easing breathing. This position can also decrease the likelihood of reflux, which can worsen coughing. Option A (using a humidifier) may help with dry air but won't directly address the cough. Option B (increasing fluid intake) may worsen coughing by increasing the need to urinate. Option C (cough suppressant) should be used cautiously in chronic bronchitis as it can hinder mucus clearance.