ATI RN
NCLEX Style Questions on Oxygenation Questions
Question 1 of 5
A patient with pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
Correct Answer: C
Rationale: The correct answer is C: Assist the patient to splint the chest when coughing. This action helps stabilize the chest wall, allowing better force generation during coughing to assist in clearing the airways. Restricting oral fluids (A) would not promote airway clearance. Teaching pursed-lip breathing (B) is beneficial for some respiratory conditions but not specifically for clearing thick sputum. Encouraging the patient to wear a nasal O2 cannula (D) is important for oxygenation but does not directly aid in airway clearance.
Question 2 of 5
Which finding in a patient with pneumonia should the nurse report immediately?
Correct Answer: A
Rationale: The correct answer is A because an oxygen saturation of 87% indicates severe hypoxemia, requiring immediate intervention to prevent complications like respiratory failure. Greenish sputum (B) suggests a possible bacterial infection but doesn't require immediate action. Fever (C) and a respiratory rate within normal range (D) are common findings in pneumonia and can be managed appropriately without immediate concern.
Question 3 of 5
The nurse evaluates a patient post-thoracentesis. Which finding requires immediate notification of the healthcare provider?
Correct Answer: B
Rationale: The correct answer is B. An oxygen saturation of 89% on room air indicates hypoxemia, which can be life-threatening and requires immediate intervention. This finding suggests inadequate oxygenation and potential respiratory distress. Choice A is within the normal range for respiratory rate. Choice C is expected after thoracentesis. Choice D, although a large amount of drainage, does not indicate an immediate concern for patient safety. In summary, the critical finding is hypoxemia, which necessitates prompt healthcare provider notification to prevent further complications.
Question 4 of 5
The nurse assesses a patient with a thoracotomy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B because chest tube drainage of 200 mL in the first hour after thoracotomy indicates active bleeding or a significant air leak, requiring immediate intervention to prevent complications like tension pneumothorax or hemorrhage. A: Oxygen saturation of 91% is concerning but not immediately life-threatening. C: Subcutaneous emphysema is expected post-thoracotomy and may not require immediate intervention. D: Diminished breath sounds may indicate a complication but are not as urgent as significant chest tube drainage.
Question 5 of 5
The nurse assesses a patient with COPD who reports increased shortness of breath. What should the nurse do first?
Correct Answer: D
Rationale: Correct Answer: D. Check the patient's oxygen saturation. Rationale: 1. Check oxygen saturation first to assess patient's oxygen levels. 2. Low oxygen saturation can indicate respiratory distress in COPD. 3. This information guides subsequent interventions. 4. Other choices address symptom management but do not address the immediate need for oxygen assessment.