ATI RN
Nursing Questions on Oxygenation Questions
Question 1 of 5
A patient with pneumonia develops confusion. What is the nurse's first action?
Correct Answer: A
Rationale: The correct first action is to assess the patient's oxygen saturation (Choice A). Confusion in a patient with pneumonia could indicate hypoxemia, so assessing oxygen saturation helps determine if the confusion is due to inadequate oxygen supply. This step is crucial for immediate intervention. Notifying the healthcare provider (Choice B) can be important but should come after assessing the patient's oxygen saturation. Administering antibiotics (Choice C) is necessary but should not be the first action when a change in mental status occurs. Reassessing vital signs (Choice D) is important but may not provide immediate information on the cause of confusion.
Question 2 of 5
A nurse is caring for a patient who is scheduled for a colonoscopy. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Administer a laxative. Administering a laxative is the first step before a colonoscopy to ensure the colon is clear for better visualization. High fiber intake (B) may be recommended after the procedure. Stool softeners (C) are used for constipation but not typically prior to a colonoscopy. Encouraging ambulation (D) is beneficial post-procedure but not the first step.
Question 3 of 5
A nurse is caring for a patient who is recovering from surgery. The patient is experiencing hypothermia. What is the priority nursing action?
Correct Answer: A
Rationale: The correct answer is A: Administer warming measures. The priority nursing action for a patient experiencing hypothermia is to prevent further heat loss and actively rewarm the patient to restore normal body temperature. This is crucial to prevent complications such as cardiac arrhythmias and impaired immune function. Administering warming measures, such as using warming blankets, heating pads, warm IV fluids, and adjusting room temperature, helps to increase the patient's core body temperature. Administering oxygen therapy (B) may be necessary for other conditions but is not the priority in this scenario. Repositioning the patient (C) may help with comfort and circulation but does not address the underlying issue of hypothermia. Administering antipyretics (D) is used to reduce fever, not hypothermia, and would not be effective in this case.
Question 4 of 5
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. Walking 15 to 20 minutes a day at least 3 times/week is appropriate for an older adult with severe COPD to gradually improve activity tolerance without overexertion. 2. Regular, moderate exercise can help improve cardiovascular function and lung capacity in COPD patients. 3. Consistent schedule of 3 times/week allows for adequate rest periods in between exercise sessions. Summary: A: Incorrect. Walking 15 to 20 minutes a day is more beneficial than just 3 times/week. B: Incorrect. Limiting exercise to ADLs may not provide enough physical activity to improve activity tolerance. C: Incorrect. Exceeding a pulse rate of 130 beats/minute may be too strenuous for an older adult with severe COPD.
Question 5 of 5
A patient with a history of heart failure is complaining of shortness of breath and chest pain. What is the priority nursing intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. In a patient with heart failure experiencing shortness of breath and chest pain, oxygen therapy is crucial to improve oxygenation and relieve symptoms. Administering oxygen helps increase oxygen saturation levels, reducing the workload on the heart. This intervention takes priority as it addresses the immediate need for adequate oxygen supply to vital organs. Administering diuretics (B) may be necessary to address fluid overload in heart failure, but oxygen therapy takes precedence in this scenario. Administering corticosteroids (D) is not indicated for acute heart failure exacerbation. Choice C is a duplicate of the correct answer and does not provide any additional rationale.