ATI RN
Fundamentals of Nursing Oxygenation Practice Questions Questions
Question 1 of 5
A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. Which finding indicates the need for immediate intervention?
Correct Answer: C
Rationale: The correct answer is C because the high-pressure alarm on the ventilator sounding indicates that the patient is experiencing increased airway pressure, which can lead to barotrauma and compromise ventilation. Immediate intervention is required to prevent lung injury. Choice A (respiratory rate of 22 breaths/min) is within the normal range and does not indicate an urgent need for intervention. Choice B (arterial oxygen saturation of 89%) is low but may not require immediate intervention as long as it is not rapidly declining and other factors are stable. Choice D (patient attempting to remove the endotracheal tube) is concerning but may not require immediate intervention as long as the airway is still secured, and other parameters are stable.
Question 2 of 5
Which action by the nurse is most important when administering a bronchodilator via nebulizer?
Correct Answer: D
Rationale: The correct answer is D: Ensuring the patient is sitting upright during the treatment. This is important because being in an upright position optimizes lung expansion and airflow, promoting better drug delivery to the lungs. Sitting upright also helps prevent potential aspiration of the medication. Choice A is incorrect because the breathing technique (in through nose, out through mouth) is not the most critical aspect of nebulizer administration. Choice B is incorrect because while monitoring for tachycardia is important, it is not the most crucial action during bronchodilator administration. Choice C is incorrect because diluting the medication with normal saline may be necessary for certain medications, but it is not the most important action when administering a bronchodilator via nebulizer.
Question 3 of 5
A patient presents with pleuritic chest pain and fever. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to assess for diminished lung sounds first. Pleuritic chest pain and fever can indicate a potential respiratory issue like pneumonia. Assessing lung sounds can provide immediate information on the patient's respiratory status and guide further interventions. Administering antipyretics can help manage the fever but does not address the underlying cause. Obtaining a sputum sample for culture is important for identifying the specific pathogen causing the infection but is not the first priority. Placing the patient in a high Fowler's position can improve oxygenation but should come after assessing lung sounds to ensure appropriate positioning.
Question 4 of 5
A patient recovering from thoracotomy reports shortness of breath and chest pain. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B: Assess for tracheal deviation. This is the priority because it can indicate a pneumothorax, a potentially life-threatening complication of thoracotomy. Tracheal deviation could suggest a tension pneumothorax, which requires immediate intervention to prevent respiratory distress and cardiac compromise. Administering analgesics (A) may be necessary but not the first priority. Encouraging the use of an incentive spirometer (C) and positioning the patient in semi-Fowler's position (D) can help improve lung function but are not as urgent as assessing for tracheal deviation.
Question 5 of 5
A patient presents with symptoms of a pulmonary embolism. What is the nurse's initial action?
Correct Answer: B
Rationale: The correct initial action for a patient with suspected pulmonary embolism is to elevate the head of the bed and apply oxygen (Choice B). Elevating the head of the bed helps improve oxygenation and reduces the workload on the heart. Providing oxygen is crucial to ensure adequate oxygen supply to the tissues. Administering anticoagulants (Choice A) should come after stabilizing the patient. Preparing for a chest x-ray (Choice C) is important but not the immediate action. Placing the patient in a supine position (Choice D) can worsen the condition by reducing blood flow to the heart.