ATI RN
NCLEX Oxygenation Practice Questions Questions
Question 1 of 5
A patient is experiencing nausea and vomiting following surgery. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: In this scenario, the correct intervention for a patient experiencing nausea and vomiting post-surgery is to apply a cold compress (Option C). This intervention helps to alleviate symptoms by providing comfort and reducing nausea through the application of cold to the forehead or back of the neck. Providing antiemetic medications (Option A) may be necessary in some cases, but addressing the discomfort and cooling effect of a cold compress should be the initial priority. Offering oral hydration (Option B) is important, but addressing the nausea and vomiting with a cold compress takes precedence. Encouraging deep breathing exercises (Option D) is beneficial for respiratory function but does not directly address the immediate symptoms of nausea and vomiting. Educationally, understanding the rationale behind prioritizing interventions based on immediate patient needs is crucial for nursing practice. It teaches students to prioritize care based on assessment findings and to address the most pressing issues first to ensure patient comfort and well-being. It also highlights the importance of quick thinking and appropriate intervention selection in emergency situations.
Question 2 of 5
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
Correct Answer: B
Rationale: The correct answer is B) UAP help splint the patient's chest during coughing. This action is incorrect because splinting the chest during coughing can restrict chest expansion, making it harder for the patient to effectively clear secretions from the lungs, which is crucial in pneumonia. Option A is correct as assisting the patient to ambulate to the bathroom promotes mobility and can help prevent complications associated with immobility. Option C is also correct as transferring the patient to a bedside chair for meals encourages activity and promotes a sense of normalcy. Option D is correct as lowering the head of the bed to 15 degrees helps improve oxygenation by reducing the risk of aspiration. Educationally, understanding the importance of proper respiratory care in pneumonia is vital for nurses and UAP to prevent complications and promote optimal patient outcomes. It is essential to reinforce the principles of chest physiotherapy and positioning techniques to support effective airway clearance in patients with respiratory conditions like pneumonia.
Question 3 of 5
A nurse is caring for a patient with a history of hypertension who is experiencing a hypertensive crisis. What is the priority intervention?
Correct Answer: B
Rationale: The correct answer is B) Administer antihypertensive medication. In a hypertensive crisis, the priority intervention is to lower the dangerously high blood pressure to prevent organ damage and complications such as stroke or heart attack. Administering antihypertensive medication promptly is crucial in this situation to rapidly reduce the blood pressure to safe levels. Option A, C, and D are incorrect because although monitoring blood pressure is important, in a hypertensive crisis, immediate intervention to lower the blood pressure takes precedence over simply monitoring. Administering antihypertensive medication is the most effective way to quickly address the dangerously high blood pressure in this critical situation. From an educational standpoint, understanding the urgency of managing hypertensive crises is vital for nurses to provide safe and effective care to patients with hypertension. Recognizing the priority interventions in emergency situations like this is essential for nurses preparing for exams like the NCLEX, where quick decision-making can make a significant impact on patient outcomes.
Question 4 of 5
A nurse is caring for a patient who is recovering from surgery. What is the priority intervention to prevent complications?
Correct Answer: C
Rationale: The correct answer is C) Encourage deep breathing exercises. The priority intervention for a patient recovering from surgery is to prevent complications such as atelectasis and pneumonia by promoting optimal lung expansion and gas exchange. Deep breathing exercises help prevent respiratory complications by improving lung ventilation and preventing the collapse of alveoli. This intervention also promotes oxygenation and aids in preventing the formation of respiratory secretions that can lead to respiratory infections. Option A) Administer pain medications may be necessary for the patient's comfort but is not the priority in preventing respiratory complications. Option B) Administer an inhaler may be indicated for patients with respiratory conditions such as asthma but is not the priority in preventing postoperative complications related to oxygenation. Option D) Administer a nebulized corticosteroid may be used for patients with specific respiratory conditions but is not the priority in preventing general postoperative respiratory complications. Educational Context: Understanding the importance of proper oxygenation and respiratory care in postoperative patients is crucial for nurses to provide optimal care and prevent complications. Encouraging deep breathing exercises is a fundamental nursing intervention to promote lung expansion, prevent atelectasis, and maintain adequate oxygenation levels in patients recovering from surgery.
Question 5 of 5
A nurse is caring for a patient with a history of myocardial infarction (MI). What is the priority action?
Correct Answer: A
Rationale: In this scenario, the priority action for a patient with a history of myocardial infarction (MI) is to administer aspirin (Option A). Aspirin is crucial in this situation because it helps prevent further clot formation by inhibiting platelet aggregation, thus reducing the risk of subsequent cardiac events. Administering oxygen therapy (Option B) may be important in some cases of MI to ensure adequate oxygenation, but in this specific situation, addressing the underlying cause of the MI is the priority. Administering short-acting bronchodilators (Option C) is more relevant in managing respiratory conditions like asthma or COPD, not in the immediate care of a patient with MI. Administering pain relief (Option D) is important but not the priority over aspirin, which directly addresses the pathophysiology of MI. Educationally, understanding the rationale behind prioritizing interventions in a patient with MI is essential for nurses preparing for the NCLEX exam. It tests the ability to prioritize care based on the patient's condition and the urgency of interventions to achieve optimal outcomes. This question highlights the critical thinking skills necessary for providing safe and effective care to patients with cardiovascular conditions.