ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 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 2 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.
Question 3 of 5
A patient with pneumonia is experiencing confusion and restlessness. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B because confusion and restlessness in a pneumonia patient may indicate hypoxia. Oxygen saturation should be reassessed as hypoxia can be life-threatening. Providing supplemental oxygen helps improve oxygenation. Administering an antipyretic (A) may help reduce fever but addressing hypoxia is more critical. Increasing fluid intake (C) and positioning the patient (D) are important but addressing hypoxia takes precedence in this scenario.
Question 4 of 5
Which finding in a patient post-lobectomy requires immediate action?
Correct Answer: B
Rationale: The correct answer is B because an oxygen saturation of 89% indicates severe hypoxemia, which can be life-threatening and requires immediate intervention to prevent tissue damage or organ failure. Oxygen is essential for cellular metabolism, and a saturation below 90% can lead to serious complications. A: Drainage of 150 mL in the first hour is within the expected range post-lobectomy and does not require immediate action. C: Mild incisional pain is a common finding post-surgery and can be managed with appropriate pain medication; it does not necessitate immediate action. D: Absent air leak in the chest tube is a desired outcome post-lobectomy, indicating proper lung re-expansion and no immediate intervention is needed in this case.
Question 5 of 5
Mrs. Mercurio has never been a smoker but has had long-term exposure to secondhand smoke. How does secondhand smoke contribute to lung diseases in adults and children?
Correct Answer: D
Rationale: The correct answer is D. Secondhand smoke can contribute to lung diseases in adults and children through various mechanisms. Firstly, it can increase mucus production, leading to airway obstruction and difficulty breathing. Secondly, it can cause developmental delays in children due to the harmful effects on their respiratory and overall health. Lastly, it impairs epithelium maturation, affecting the lining of the respiratory tract and making individuals more susceptible to infections and respiratory diseases. Therefore, all of the above choices are correct in explaining how secondhand smoke contributes to lung diseases.