ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
A patient has a positive Mantoux test. What is the next step in care?
Correct Answer: B
Rationale: The correct next step is to schedule a chest x-ray to evaluate for active tuberculosis. A positive Mantoux test indicates exposure to the tuberculosis bacteria but doesn't confirm active disease. A chest x-ray helps determine if there is active infection in the lungs. Starting four-drug therapy for tuberculosis (A) is premature without confirming active disease. Repeating the Mantoux test (C) is unnecessary as it won't differentiate between latent and active infection. Administering the BCG vaccine (D) is not indicated in this case as the patient already has a positive Mantoux test.
Question 2 of 5
Which nursing action is most effective in preventing ventilator-associated pneumonia (VAP)?
Correct Answer: A
Rationale: The correct answer is A: Performing oral care with chlorhexidine. This action is effective in preventing VAP by reducing the bacterial load in the oral cavity, which can decrease the risk of aspiration of pathogens into the lungs. Chlorhexidine has antimicrobial properties that help to kill or inhibit the growth of bacteria. Regular oral care can help maintain oral hygiene and prevent colonization of pathogens. Choice B, administering antibiotics prophylactically, is not recommended as routine prophylactic use of antibiotics can lead to antibiotic resistance and disrupt the normal flora, potentially causing more harm than good. Choice C, suctioning the airway every hour, is important for maintaining airway patency but is not the most effective action for preventing VAP. Over-suctioning can irritate the airway and increase the risk of infection. Choice D, keeping the patient sedated at all times, is not a recommended practice as it can lead to complications such as ventilator-associated pneumonia. Sedation can impair the
Question 3 of 5
Which finding in a patient with pneumonia requires immediate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B because an oxygen saturation of 88% indicates severe hypoxemia, requiring immediate intervention to prevent tissue damage. Oxygen therapy is crucial to improve oxygenation. Choice A is not as urgent as hypoxemia. Choice C indicates fluid in the lungs but does not require immediate action. Choice D is within the normal range for respiratory rate.
Question 4 of 5
A patient with pneumonia has an oxygen saturation of 88%. What is the nurse's priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy immediately. With an oxygen saturation of 88%, the patient is experiencing hypoxemia, which can lead to tissue damage and organ dysfunction. Administering oxygen therapy is crucial to improve oxygen levels and prevent further complications. Other choices are incorrect because: B: Encouraging deep breathing and coughing may be beneficial, but addressing hypoxemia is the priority. C: Obtaining a sputum culture is important but not immediate in this situation. D: Positioning the patient in high Fowler's position can help with breathing, but addressing the low oxygen saturation is the priority.
Question 5 of 5
A patient receiving mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). What is the best intervention?
Correct Answer: B
Rationale: The correct answer is B: Perform oral care with chlorhexidine. This intervention helps reduce the risk of VAP by decreasing oral bacteria that can potentially be aspirated into the lungs. Proper oral care is essential in preventing VAP. Administering prophylactic antibiotics (A) may lead to antibiotic resistance. Keeping the patient sedated at all times (C) can increase the risk of aspiration. Increasing the frequency of suctioning (D) can irritate the airway and potentially introduce more bacteria.