ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
A patient with chronic obstructive pulmonary disease (COPD) has an oxygen saturation of 88%. What should the nurse do next?
Correct Answer: A
Rationale: The correct answer is A because maintaining oxygen saturation above 90% is essential for patients with COPD to prevent further respiratory complications. Oxygen therapy helps improve oxygen levels in the blood, reducing the workload on the heart and improving overall oxygen delivery to tissues. Administering oxygen is the immediate intervention needed to improve the patient's oxygen saturation. Option B is incorrect as deep breathing exercises alone may not be sufficient to increase oxygen levels in the blood significantly. Option C is incorrect because notifying the healthcare provider is not the immediate action needed to address the low oxygen saturation. Option D is incorrect as monitoring respiratory rate alone does not address the immediate need to improve oxygen saturation levels.
Question 2 of 5
Which finding in a patient with pneumonia requires immediate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B because an oxygen saturation of 88% indicates severe hypoxemia, requiring immediate intervention to prevent tissue damage. Oxygen therapy is crucial to improve oxygenation. Choice A is not as urgent as hypoxemia. Choice C indicates fluid in the lungs but does not require immediate action. Choice D is within the normal range for respiratory rate.
Question 3 of 5
A patient with pneumonia has an oxygen saturation of 88%. What is the nurse's priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy immediately. With an oxygen saturation of 88%, the patient is experiencing hypoxemia, which can lead to tissue damage and organ dysfunction. Administering oxygen therapy is crucial to improve oxygen levels and prevent further complications. Other choices are incorrect because: B: Encouraging deep breathing and coughing may be beneficial, but addressing hypoxemia is the priority. C: Obtaining a sputum culture is important but not immediate in this situation. D: Positioning the patient in high Fowler's position can help with breathing, but addressing the low oxygen saturation is the priority.
Question 4 of 5
A patient receiving mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). What is the best intervention?
Correct Answer: B
Rationale: The correct answer is B: Perform oral care with chlorhexidine. This intervention helps reduce the risk of VAP by decreasing oral bacteria that can potentially be aspirated into the lungs. Proper oral care is essential in preventing VAP. Administering prophylactic antibiotics (A) may lead to antibiotic resistance. Keeping the patient sedated at all times (C) can increase the risk of aspiration. Increasing the frequency of suctioning (D) can irritate the airway and potentially introduce more bacteria.
Question 5 of 5
The nurse assesses a patient with a chest tube and notes subcutaneous emphysema. What is the appropriate action?
Correct Answer: B
Rationale: The correct answer is B: Document the finding and continue monitoring. Subcutaneous emphysema in a patient with a chest tube indicates air leakage but does not require immediate intervention. Clamping the chest tube could lead to tension pneumothorax. Notifying the healthcare provider is important but not urgent unless other symptoms are present. Replacing the chest tube drainage system is not necessary at this point. Regular monitoring and documentation allow for appropriate intervention if the condition worsens.