ATI RN
NCLEX Questions Oxygen Therapy Questions
Question 1 of 5
A patient with a tracheostomy is unable to clear secretions. What is the nurse's next action?
Correct Answer: A
Rationale: The correct answer is A: Perform tracheal suctioning. When a patient with a tracheostomy is unable to clear secretions, suctioning is necessary to remove the accumulated secretions and maintain a clear airway. This prevents potential complications such as airway obstruction and respiratory distress. Administering a mucolytic (B) may help loosen secretions but does not address the immediate need for clearing them. Encouraging the patient to cough forcefully (C) may not be effective if the secretions are too thick or if the patient is unable to cough effectively. Increasing fluid intake (D) may help in thinning secretions but will not address the immediate need for clearing them.
Question 2 of 5
A patient recovering from thoracentesis reports worsening dyspnea. What is the nurse's first action?
Correct Answer: B
Rationale: The correct first action is to assess oxygen saturation (Choice B) to determine the patient's respiratory status. This step is crucial in identifying if the patient is hypoxic, which could be life-threatening. Encouraging deep breathing (Choice A) may worsen dyspnea if there is an underlying respiratory compromise. Notifying the healthcare provider (Choice C) should come after assessing the oxygen saturation. Positioning the patient in high Fowler's (Choice D) may provide comfort but does not address the immediate need to assess oxygen saturation for appropriate intervention.
Question 3 of 5
Which assessment finding indicates that a patient with COPD requires immediate intervention?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation of 85% on room air. A low oxygen saturation level indicates hypoxemia, which can be life-threatening in patients with COPD. Immediate intervention is needed to improve oxygenation. Option B is related to barrel chest, common in COPD but not an immediate concern. Option C indicates an infection which may require treatment but not immediate intervention. Option D is within normal range and does not indicate an urgent need for intervention.
Question 4 of 5
A patient is scheduled for a thoracentesis. What position is appropriate for the procedure?
Correct Answer: B
Rationale: The correct position for a thoracentesis is sitting upright leaning over a table. This position allows for better expansion of the lung and easier access to the pleural space. Gravity helps the pleural fluid accumulate at the base of the lung, making the procedure safer and more successful. Supine position (A) may not allow proper access to the pleural space. Prone position (C) is not ideal as it can hinder lung expansion. Lying on the unaffected side (D) can also impede lung expansion and fluid accumulation at the desired site.
Question 5 of 5
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?
Correct Answer: D
Rationale: The correct answer is D because negative sputum smears for acid-fast bacilli indicate the absence of active TB infection and therefore, discontinuing airborne precautions would be appropriate. A: Upper lobe infiltrates are common in TB. B: 6 months of TB medication doesn't indicate immediate safety. C: An induration of 10 mm in Mantoux testing could still indicate active infection.