ATI RN
NCLEX Questions on Oxygenation and Perfusion Questions
Question 1 of 5
A patient with a history of heart failure is experiencing shortness of breath. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer supplemental oxygen. In a patient with heart failure experiencing shortness of breath, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress. This is crucial to prevent further deterioration and potential complications. Administering a diuretic (B) would help with fluid overload but does not address the immediate need for oxygen. Administering an IV analgesic (C) is not indicated for shortness of breath in heart failure. Administering a vasodilator (D) may worsen the condition by decreasing blood pressure and cardiac output.
Question 2 of 5
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
Correct Answer: C
Rationale: The correct answer is C: How long has it been since you moved to the United States? This question is important because TB prevalence varies in different countries, and individuals who have recently immigrated from high TB burden countries may have a higher risk of TB infection. It helps the nurse assess the individual's potential exposure risk. A: Do you take any over-the-counter (OTC) medications? - This question is not directly related to TB skin testing and does not provide information relevant to assessing TB risk. B: Do you have any family members with a history of TB? - While a family history of TB can be a risk factor, it is not as directly relevant as the timing of immigration in this context. D: Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB? - While BCG vaccination history is important for interpreting TB skin test results, it is not as crucial as determining recent immigration status when assessing TB risk.
Question 3 of 5
A nurse is caring for a patient who is recovering from surgery. What is the priority intervention to prevent deep vein thrombosis (DVT)?
Correct Answer: D
Rationale: The correct answer is A: Encourage early ambulation. This is the priority intervention to prevent DVT because it promotes blood circulation and prevents stasis in the veins. - Option B: Administer a platelet aggregation inhibitor is incorrect as it is not the first-line intervention for preventing DVT. - Option C: Administer anticoagulants may be used in some cases, but it is not the priority intervention. - Option D: Monitor the patient's oxygen saturation levels is not directly related to preventing DVT and is not the priority intervention.
Question 4 of 5
A nurse is caring for a patient with a history of diabetes who is experiencing blurred vision. What is the priority action?
Correct Answer: C
Rationale: The correct answer is C: Administer insulin. Blurred vision in a patient with a history of diabetes could indicate hyperglycemia. Administering insulin would help lower blood glucose levels and alleviate the blurred vision. Monitoring blood glucose levels (choice A) is important but not the priority when the patient is already experiencing symptoms. Administering insulin (choices B and D) is the immediate action needed to address the high blood glucose levels causing the blurred vision.
Question 5 of 5
A nurse is caring for a patient with a history of heart failure. The patient is experiencing fatigue and weakness. What is the priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In heart failure, fatigue and weakness can be due to poor oxygenation. Administering oxygen helps improve oxygen levels, alleviating symptoms. Insulin (B) is not indicated for fatigue in heart failure. Antibiotics (C) are not necessary unless there is a confirmed infection. Beta-blockers (D) may be part of the treatment plan but addressing oxygenation is the priority in this scenario.