ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 of 5
How deep should an oral ETT be inserted into a 4-year-old patient measured at the teeth?
Correct Answer: A
Rationale: In pediatric patients, the correct depth for inserting an oral endotracheal tube (ETT) is crucial to ensure proper placement and optimal oxygenation. For a 4-year-old child, the recommended depth for an oral ETT insertion measured at the teeth is typically around 13-14 cm, which is option A. The rationale behind this specific depth is based on the anatomy of a 4-year-old child. Inserting the ETT to this depth ensures that the tube reaches the optimal position in the trachea for effective ventilation while minimizing the risk of complications such as accidental extubation or inadequate oxygenation. Option B (14-15 cm), C (15-16 cm), and D (16-17 cm) are incorrect because inserting the ETT to these depths could lead to improper placement, potentially causing complications like endobronchial intubation, inadequate ventilation, or injury to surrounding structures. Educationally, understanding the correct ETT insertion depth for pediatric patients is essential for nurses and healthcare providers caring for children requiring respiratory support. It highlights the importance of precise measurements and considerations based on age-specific guidelines to ensure safe and effective airway management in pediatric patients.
Question 2 of 5
A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?
Correct Answer: B
Rationale: In teaching a home care patient and their family about using prescribed oxygen, it is critical to include safety measures necessary to prevent a fire. This is the correct answer because oxygen supports combustion, making the environment highly flammable. Educating patients and families about fire safety precautions such as keeping the oxygen away from heat sources, open flames, and ensuring proper ventilation is crucial to prevent fire accidents which can be life-threatening. Option A, the importance of communicating with the patient, is important in general patient education but not as critical as fire safety in this specific context. Option C, the cost and source of supply for the oxygen, is important but not as immediate as ensuring safety. Option D, the need to provide good skin care, is not directly related to the safe use of prescribed oxygen. In an educational context, emphasizing fire safety when teaching about oxygen use ensures that patients and families understand the potential risks associated with oxygen therapy and empowers them to take necessary precautions to prevent accidents. It also highlights the nurse's role in promoting patient safety and well-being beyond just administering treatments.
Question 3 of 5
A nurse is assessing a client who has COPD. The nurse should identify which of the following is an expected finding?
Correct Answer: B
Rationale: In this NCLEX-style question regarding a client with COPD, the correct answer is B) Clubbing of the fingers. Clubbing is a common finding in individuals with chronic respiratory conditions like COPD due to chronic hypoxia. Clubbing is characterized by the enlargement of the fingertips and the abnormal curving of the nails. This occurs as a result of chronic tissue hypoxia leading to changes in the nail bed and soft tissues of the fingers. Option A) Jugular vein distention is not typically associated with COPD but may be seen in conditions like heart failure. Option C) Heart murmur is not a typical finding in COPD but may be present in conditions like valvular heart disease. Option D) Paradoxical breathing is not a common finding in COPD but is seen in conditions like diaphragmatic paralysis. Educationally, understanding these expected findings in COPD patients is crucial for nurses to provide comprehensive care, assess for complications, and intervene appropriately. Recognizing clubbing in a patient with COPD can prompt further assessment and interventions to manage the condition effectively. This knowledge enhances nurses' ability to provide holistic care to clients with respiratory conditions.
Question 4 of 5
The nurse expects a patient with angina pectoris to
Correct Answer: A
Rationale: Patients with angina pectoris commonly experience symptoms that are similar to indigestion after eating a heavy meal. This is because angina is caused by reduced blood flow to the heart muscles due to coronary artery disease. The discomfort from angina can be triggered by activities that increase the heart's workload, such as eating a large meal that requires increased blood flow to the digestive system. The pain or discomfort associated with angina can feel like a squeezing sensation in the chest, often described by patients as similar to heartburn or indigestion. Therefore, the nurse can expect a patient with angina pectoris to experience feelings of indigestion after eating a heavy meal. It is important for healthcare providers to recognize these symptoms to provide appropriate care and treatment for angina.
Question 5 of 5
A nurse is caring for a client who has atelectasis. The nurse should identify which of the following substances is required to keep the client's alveoli from collapsing?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Surfactant. Surfactant is a substance produced by the alveoli in the lungs that helps reduce surface tension, preventing alveolar collapse or atelectasis. When alveoli collapse, it can lead to decreased gas exchange and impaired oxygenation. By maintaining the surface tension at the alveoli, surfactant plays a crucial role in maintaining lung compliance and preventing atelectasis. Looking at the other options: A) Lymphatic fluid: Lymphatic fluid does not play a direct role in preventing alveolar collapse. Its main function is to transport immune cells and maintain fluid balance in the body. B) Oxygenated blood: While oxygenated blood is essential for gas exchange in the alveoli, it does not directly prevent alveolar collapse. C) Synovial fluid: Synovial fluid is found in joints and helps reduce friction between articulating surfaces. It is not involved in preventing alveolar collapse. In an educational context, understanding the role of surfactant in maintaining lung function is crucial for nursing practice. Nurses need to be aware of the factors that can lead to atelectasis and the interventions, such as positioning, deep breathing exercises, and mobilization, that can help prevent it. Knowledge of the respiratory system and its components is essential for providing effective care to patients with respiratory conditions.