ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 of 5
Nasopharyngeal suctioning is designed to remove which of the following from the upper respiratory tract?
Correct Answer: A
Rationale: The correct answer is A: Accumulated secretions. Nasopharyngeal suctioning is used to remove excess mucus, secretions, or fluids from the upper respiratory tract to maintain airway patency and prevent aspiration. Accumulated secretions can obstruct the airway and impair breathing. Choice B, acidosis, is incorrect as it pertains to a metabolic condition of increased acidity in the body, not a physical obstruction. Choice C, bronchi, is incorrect as bronchi are a part of the lower respiratory tract, not the upper respiratory tract. Choice D, cyanosis, is also incorrect as it refers to a bluish discoloration of the skin or mucous membranes due to lack of oxygen, not something physically removed during suctioning.
Question 2 of 5
A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Cover your nose with the CPAP nose. The rationale for this is that the CPAP machine is designed to deliver pressurized air through a mask that covers the nose and/or mouth to keep the airway open during sleep. This ensures that the client receives the appropriate pressure to prevent airway collapse and maintain effective breathing patterns. Choice A is incorrect because using the CPAP mask during the daytime is not necessary and could be uncomfortable for the client. Choice C is incorrect as medications are not administered through the CPAP machine. Choice D is incorrect as supplemental oxygen is not typically needed with CPAP therapy unless prescribed by a healthcare provider for specific medical reasons.
Question 3 of 5
A nurse is planning care for a client at risk of developing ventilator-associated pneumonia (VAP). Which of the following interventions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: Elevate the head of the bed to 45 degrees. This intervention helps prevent aspiration and reduces the risk of VAP by promoting proper lung expansion and drainage of secretions. Elevating the head of the bed also decreases the risk of reflux and aspiration of oral secretions. Limiting oral hygiene (A) to once a day can increase the risk of bacterial buildup in the mouth. Performing deep suctioning (C) every 2 hours can cause trauma to the airway and increase the risk of infection. Placing the client in the prone position (D) can lead to decreased lung expansion and impaired secretion drainage, increasing the risk of VAP.
Question 4 of 5
A patient with a history of pulmonary edema is admitted with shortness of breath. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C: Place the patient in a high Fowler's position. This is the priority action because it helps improve oxygenation by reducing pressure on the diaphragm and increasing lung expansion. Elevating the head of the bed also helps decrease the workload of the heart and improves ventilation. Administering diuretics (choice A) can be important but is not the immediate priority. Assessing lung sounds (choice B) is important but not the most critical action at this moment. Notifying the healthcare provider (choice D) can be done after the patient's immediate needs are addressed.
Question 5 of 5
A nurse is providing discharge teaching to a client with pulmonary hypertension. Which statement indicates a need for further teaching?
Correct Answer: B
Rationale: The correct answer is B because taking over-the-counter decongestants can worsen pulmonary hypertension by increasing pulmonary vascular resistance. A is correct as weight monitoring can detect fluid retention. C is correct as strenuous activities can strain the heart. D is correct as increased shortness of breath may indicate worsening condition.