ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 of 5
A patient presents with sudden chest pain and dyspnea. Which condition should the nurse suspect?
Correct Answer: A
Rationale: The correct answer is A: Pulmonary embolism. Sudden chest pain and dyspnea are classic symptoms of a pulmonary embolism, which is a blockage in one of the pulmonary arteries. This condition requires immediate medical attention due to the risk of serious complications like pulmonary infarction. Pneumothorax (B) presents with sharp chest pain and shortness of breath but is more commonly associated with trauma or underlying lung disease. Pneumonia (C) typically presents with gradual onset of symptoms such as fever and productive cough. Asthma attack (D) presents with wheezing and coughing, usually triggered by allergens or exercise.
Question 2 of 5
The nurse assesses a patient with a chest tube and observes continuous bubbling in the water-seal chamber. What is the nurse's next action?
Correct Answer: C
Rationale: The correct next action is to assess the system for an air leak. This is because continuous bubbling in the water-seal chamber indicates air is escaping from the patient's chest cavity through the tube. By assessing the system for an air leak, the nurse can identify and address the source of the problem. Clamping the chest tube (choice A) can lead to a tension pneumothorax and is not appropriate. Adding more water (choice B) is incorrect as it will not address the underlying issue. Replacing the entire system (choice D) is unnecessary without first identifying the specific problem.
Question 3 of 5
The nurse observes an air leak in the water-seal chamber of a patient's chest tube. What is the best action?
Correct Answer: C
Rationale: The correct answer is C: Assess the system for loose connections or dislodgment. This is the best action because identifying the cause of the air leak is crucial before taking any further steps. Clamping the chest tube (A) can lead to tension pneumothorax. Notifying the healthcare provider (B) is important but does not address the immediate need to assess the system. Increasing suction (D) can worsen the situation if the cause of the air leak is not resolved. Overall, assessing the system first ensures proper management and prevents potential complications.
Question 4 of 5
Which intervention is most important when caring for a patient with a pulmonary embolism (PE)?
Correct Answer: B
Rationale: Correct Answer: B - Administer anticoagulant therapy as prescribed. Rationale: 1. Anticoagulant therapy helps prevent further clot formation in the lungs. 2. It helps dissolve existing clots and improve blood flow. 3. This intervention is crucial in managing and treating pulmonary embolism effectively. Summary: - A: Placing the patient in a supine position may worsen the condition by reducing blood flow to the lungs. - C: Deep breathing exercises are beneficial, but anticoagulant therapy takes precedence. - D: Restricting fluid intake is not a priority in the management of a pulmonary embolism.
Question 5 of 5
What is the priority nursing action for a patient presenting with possible pulmonary embolism?
Correct Answer: B
Rationale: The correct answer is B because applying oxygen and elevating the head of the bed will help improve oxygenation and reduce the workload on the heart. This is crucial in a patient with possible pulmonary embolism to prevent further complications. Administering anticoagulants (A) is important but not the priority as oxygenation takes precedence. Chest x-ray (C) can help confirm diagnosis but is not immediate. Notifying the healthcare provider (D) is important but not as urgent as ensuring adequate oxygenation.