ATI RN
Oxygenation NCLEX Questions Questions
Question 1 of 5
A patient reports severe chest pain and difficulty breathing after a thoracentesis. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C because reassessing vital signs and oxygen saturation is crucial to determine the patient's current status and the severity of the symptoms. This step allows the nurse to quickly identify any potential complications or deterioration in the patient's condition. Administering analgesic (choice A) may temporarily alleviate pain but does not address the underlying issue. Notifying the healthcare provider (choice B) is important but should not delay immediate assessment and intervention. Positioning the patient on the affected side (choice D) is not appropriate in this scenario and may worsen the symptoms.
Question 2 of 5
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Auscultate anterior and posterior breath sounds bilaterally. This is the next appropriate action after noting absent fremitus during palpation of the posterior chest. Auscultation helps assess breath sounds and detects abnormalities such as wheezing or crackles. It provides valuable information about the patient's lung health and can help identify potential respiratory issues. Palpating the anterior chest or observing for barrel chest (choice A) is not the immediate priority when fremitus is absent. Encouraging the patient to turn, cough, and deep breathe (choice B) may be beneficial but does not directly address the absence of fremitus. Reviewing the chest x-ray report for evidence of pneumonia (choice C) is important but does not address the immediate need to further assess breath sounds in this scenario.
Question 3 of 5
A patient with a history of asthma is admitted with an exacerbation. Which action should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Administer a short-acting bronchodilator. The first step in managing an asthma exacerbation is to provide quick relief by administering a short-acting bronchodilator like albuterol. This medication helps to open up the airways rapidly, providing immediate relief of symptoms such as wheezing and shortness of breath. Administering a bronchodilator is crucial in the acute management of an asthma exacerbation as it targets bronchoconstriction. Oral steroids (choice C) are typically used for more severe exacerbations or when initial bronchodilator therapy is ineffective. Administering an inhaled beta-agonist (choice D) is a valid option, but a short-acting bronchodilator is preferred for immediate relief in the initial management of an exacerbation.
Question 4 of 5
A nurse is caring for a patient with a history of asthma. Which intervention should the nurse prioritize?
Correct Answer: D
Rationale: The correct answer is D: Administer a bronchodilator. This is the priority intervention because bronchodilators help to quickly open the airways during an asthma attack, improving breathing. Administering a bronchodilator is crucial for managing acute asthma symptoms. Encouraging the patient to avoid triggers (choice B) is important for long-term asthma management but not the priority during an acute attack. Administering an inhaled corticosteroid (choice C) is more for long-term control and prevention of asthma symptoms, not for immediate relief during an attack. Choice A is a duplicate of the correct answer and does not provide additional information.
Question 5 of 5
A patient with a history of heart failure is experiencing shortness of breath. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the priority in a patient with heart failure experiencing shortness of breath to improve oxygenation and reduce workload on the heart. Oxygen therapy helps alleviate symptoms and prevent further complications. Administering morphine (choice B) is not the first priority as it can depress the respiratory system and mask important symptoms. Monitoring respiratory status (choice C) is important but providing oxygen takes precedence to address the immediate need for improved oxygenation. Choice D is a duplicate of choice A, making it incorrect.