ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
A patient with asthma reports increased use of a rescue inhaler. What is the nurse's priority intervention?
Correct Answer: C
Rationale: The correct answer is C: Perform a peak expiratory flow reading. This is the priority intervention because it helps assess the severity of the patient's asthma exacerbation objectively. By measuring the peak expiratory flow, the nurse can determine the degree of airflow limitation and response to treatment. This information guides appropriate interventions and helps in monitoring the effectiveness of the treatment. Notification of the healthcare provider (choice A) can be important but assessing the patient's respiratory status takes precedence. Teaching proper inhaler technique (choice B) and assessing adherence to maintenance medication (choice D) are important interventions but not the immediate priority when the patient is experiencing increased symptoms.
Question 2 of 5
A patient with a tracheostomy tube exhibits difficulty breathing and thick secretions. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B - Perform tracheal suctioning. This action helps clear the thick secretions that are causing difficulty breathing. Tracheal suctioning is necessary for patients with tracheostomy tubes to maintain a clear airway. Encouraging deep breathing and coughing (choice A) may not be effective in clearing thick secretions from the trachea. Administering a bronchodilator (choice C) may help with bronchospasm but does not address the underlying issue of thick secretions. Repositioning the patient (choice D) may provide some relief but does not directly address the problem of airway obstruction due to thick secretions.
Question 3 of 5
The nurse observes continuous bubbling in the water-seal chamber of a chest tube. What does this indicate?
Correct Answer: B
Rationale: The continuous bubbling in the water-seal chamber indicates an air leak in the system. When air leaks into the chest tube system, it creates bubbling in the water-seal chamber. This indicates that the system is not airtight, compromising its ability to remove air or fluid from the pleural space effectively. Choices A, C, and D are incorrect because continuous bubbling does not indicate proper functioning of the chest tube, presence of a pneumothorax, or high suction pressure.
Question 4 of 5
A patient with pulmonary embolism (PE) is receiving heparin therapy. What lab result should the nurse monitor closely?
Correct Answer: B
Rationale: The correct answer is B, activated partial thromboplastin time (aPTT). Monitoring aPTT is crucial for patients on heparin therapy to ensure the therapeutic range is maintained for anticoagulation. A prolonged aPTT indicates the desired anticoagulant effect of heparin. Platelet count (A) is important to monitor for heparin-induced thrombocytopenia, not routine monitoring. Prothrombin time (PT) (C) and international normalized ratio (INR) (D) are used to monitor warfarin therapy, not heparin.
Question 5 of 5
Which intervention should the nurse implement for a patient with a chest tube and continuous bubbling in the water-seal chamber?
Correct Answer: D
Rationale: The correct answer is D because checking all connections for a loose fitting is essential in this situation. This step ensures that there are no leaks or disconnections along the chest tube system, which could be causing the continuous bubbling in the water-seal chamber. Clamping the chest tube (Choice A) could lead to a tension pneumothorax and is not recommended. Notifying the healthcare provider of an air leak (Choice B) can be done after checking the connections. Repositioning the tubing (Choice C) may not address the underlying issue of a loose connection.