ATI RN
NCLEX Practice Questions Oxygenation Questions
Question 1 of 5
A patient with tuberculosis is started on isoniazid. Which side effect should the nurse monitor for?
Correct Answer: A
Rationale: The correct answer is A) Peripheral neuropathy. Isoniazid, a medication commonly used to treat tuberculosis, can lead to peripheral neuropathy as a side effect. This occurs due to the depletion of vitamin B6 (pyridoxine) by isoniazid, leading to nerve damage. Monitoring for symptoms such as numbness, tingling, or burning sensations in the extremities is crucial to prevent worsening of this condition. Option B) Orange discoloration of body fluids is incorrect as this side effect is associated with rifampin, another medication used in TB treatment. Option C) Visual changes are not typically associated with isoniazid use. Option D) Hearing loss is not a known side effect of isoniazid. In an educational context, understanding the side effects of medications used in the treatment of tuberculosis is essential for nurses caring for patients with this condition. Monitoring for and recognizing potential adverse effects early can help in providing safe and effective care to patients undergoing TB treatment.
Question 2 of 5
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
Correct Answer: B
Rationale: In the context of a patient with bacterial pneumonia exhibiting coarse crackles and thick sputum, the correct action to promote airway clearance is to teach the pursed-lip breathing technique (Option B). This technique helps improve oxygenation and facilitates the removal of secretions by creating positive pressure in the airways during exhalation. Option A, restricting oral fluids during the day, is incorrect as hydration is essential for thinning respiratory secretions, making them easier to expectorate. Option C, encouraging the patient to wear the nasal O2 cannula, is also incorrect because while oxygen therapy may be necessary, it does not directly address airway clearance. Option D, assisting the patient to splint the chest when coughing, is not the most effective intervention for promoting airway clearance in this scenario. From an educational standpoint, understanding the rationale behind the correct answer is crucial for nursing students preparing for the NCLEX exam. Teaching them the pursed-lip breathing technique equips them with a practical skill that can be applied in real clinical situations to improve patient outcomes, especially in cases of respiratory conditions like pneumonia where airway clearance is a priority.
Question 3 of 5
A nurse is caring for a postoperative patient. Which action should the nurse take to prevent deep vein thrombosis (DVT)?
Correct Answer: D
Rationale: The correct answer is D) Assist the patient with physical therapy. Rationale: 1. **Correct Answer (D):** Physical therapy helps prevent DVT by promoting circulation and preventing blood stasis. Physical activity encourages muscle contractions, which in turn aids in venous return, reducing the risk of clot formation. 2. **Incorrect Answers:** - A) Encouraging early ambulation is important in preventing DVT, but physical therapy involves more structured exercise routines tailored to the patient's needs. - B) While compression stockings can help with DVT prevention, they are not as effective as physical therapy in promoting muscle movement and circulation. - C) Administering aspirin is not primarily used for DVT prevention. Aspirin is more commonly used for its antiplatelet effects in conditions like heart disease. 3. **Educational Context:** - Understanding the importance of preventing DVT postoperatively is crucial for nurses caring for surgical patients. - Physical therapy plays a significant role in preventing complications like DVT in immobile or postoperative patients by promoting mobility and circulation. - Nurses should be knowledgeable about various strategies to prevent DVT and tailor interventions based on individual patient needs to ensure optimal outcomes.
Question 4 of 5
A nurse is caring for a patient with a history of myocardial infarction (MI). The patient is complaining of chest pain. What is the priority intervention?
Correct Answer: B
Rationale: In this scenario, the priority intervention for a patient with a history of myocardial infarction (MI) complaining of chest pain is to administer morphine (Option B). The rationale behind choosing morphine as the correct answer is that it helps to relieve chest pain by decreasing the workload of the heart and reducing anxiety, thereby improving oxygenation to the heart muscle. This is crucial in a patient with a history of MI as chest pain could be indicative of ongoing ischemia or infarction. Administering nitroglycerin (Option A) is also a common intervention for chest pain in MI patients, as it helps to dilate blood vessels and improve blood flow to the heart. However, in this case, morphine takes precedence due to its broader pain-relieving and calming effects. Providing pain relief (Option C) is a general intervention but does not address the specific needs of a patient with a history of MI experiencing chest pain. Administering oral anticoagulants (Option D) is not appropriate as the immediate concern is managing the current chest pain and potential cardiac complications. Educationally, understanding the rationale behind prioritizing certain interventions in acute cardiac situations like MI is crucial for nurses to provide timely and effective care, which can ultimately save lives and prevent further cardiac damage.
Question 5 of 5
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?
Correct Answer: B
Rationale: In this scenario, the nurse should prioritize option B: Notify the patient's health care provider. This action is crucial because the patient is presenting with symptoms that are indicative of a possible pulmonary embolism, a serious condition that requires immediate medical attention. Contacting the healthcare provider allows for prompt assessment, further diagnostic testing, and initiation of appropriate treatment. Option A (Administer anticoagulant drug therapy) is incorrect because administering medication without a proper diagnosis and healthcare provider's orders can be dangerous and may worsen the patient's condition if the diagnosis is incorrect. Option C (Prepare patient for a spiral CT) is also incorrect as it involves a diagnostic procedure that should be ordered by the healthcare provider after assessment and evaluation. It is not the nurse's role to independently order diagnostic tests. Option D (Elevate the head of the bed to a semi-Fowler's position) is a supportive measure but is not the priority in this situation. The patient's critical condition requires immediate medical intervention. Educationally, this question highlights the importance of prioritizing patient care based on assessment findings and the urgency of the situation. Nurses need to recognize emergent situations, collaborate with healthcare providers, and follow proper protocols to ensure optimal patient outcomes.