ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 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.
Question 2 of 5
A patient with pneumonia is experiencing confusion and restlessness. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B because confusion and restlessness in a pneumonia patient may indicate hypoxia. Oxygen saturation should be reassessed as hypoxia can be life-threatening. Providing supplemental oxygen helps improve oxygenation. Administering an antipyretic (A) may help reduce fever but addressing hypoxia is more critical. Increasing fluid intake (C) and positioning the patient (D) are important but addressing hypoxia takes precedence in this scenario.
Question 3 of 5
Which finding in a patient post-lobectomy requires immediate action?
Correct Answer: B
Rationale: The correct answer is B because an oxygen saturation of 89% indicates severe hypoxemia, which can be life-threatening and requires immediate intervention to prevent tissue damage or organ failure. Oxygen is essential for cellular metabolism, and a saturation below 90% can lead to serious complications. A: Drainage of 150 mL in the first hour is within the expected range post-lobectomy and does not require immediate action. C: Mild incisional pain is a common finding post-surgery and can be managed with appropriate pain medication; it does not necessitate immediate action. D: Absent air leak in the chest tube is a desired outcome post-lobectomy, indicating proper lung re-expansion and no immediate intervention is needed in this case.
Question 4 of 5
Mrs. Mercurio has never been a smoker but has had long-term exposure to secondhand smoke. How does secondhand smoke contribute to lung diseases in adults and children?
Correct Answer: D
Rationale: The correct answer is D. Secondhand smoke can contribute to lung diseases in adults and children through various mechanisms. Firstly, it can increase mucus production, leading to airway obstruction and difficulty breathing. Secondly, it can cause developmental delays in children due to the harmful effects on their respiratory and overall health. Lastly, it impairs epithelium maturation, affecting the lining of the respiratory tract and making individuals more susceptible to infections and respiratory diseases. Therefore, all of the above choices are correct in explaining how secondhand smoke contributes to lung diseases.
Question 5 of 5
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention?
Correct Answer: C
Rationale: The priority nursing intervention for a patient with COPD is to encourage the patient to rest (Choice C). This is because in COPD, the patient often experiences difficulty breathing, leading to increased work of breathing and fatigue. Rest allows the patient to conserve energy, reduce oxygen demand, and prevent exacerbation of symptoms. Encouraging deep breathing exercises (Choice A) may be beneficial for lung expansion but can also increase the work of breathing and lead to fatigue. While fluid intake (Choice B) is important for overall health, it is not the priority in managing acute COPD exacerbation. Using a peak flow meter (Choice D) is more relevant for monitoring asthma rather than COPD. Thus, the correct answer is C as it addresses the immediate need to reduce the patient's respiratory workload and promote recovery.