ATI RN
Oxygenation NCLEX Questions Quizlet Questions
Question 1 of 5
The nurse assesses a patient diagnosed with idiopathic pulmonary arterial hypertension (IPAH). Which finding requires the most immediate action?
Correct Answer: C
Rationale: The correct answer is C because the discontinuation of epoprostenol infusion in a patient with IPAH can lead to a sudden and severe worsening of symptoms, including potentially life-threatening pulmonary hypertension crisis. This requires immediate action to prevent complications. A: An O2 saturation of 90% is within an acceptable range and does not indicate an immediate crisis. B: A blood pressure of 98/56 mm Hg is slightly low but not critically abnormal to require immediate intervention. D: A prolonged INR may indicate altered coagulation but is not an immediate concern compared to the abrupt discontinuation of a critical medication like epoprostenol.
Question 2 of 5
Which intervention is a priority for a patient experiencing severe respiratory distress?
Correct Answer: C
Rationale: The correct answer is C because positioning the patient upright and providing oxygen therapy is crucial in severe respiratory distress to optimize oxygenation. This position helps improve lung expansion and ventilation. Administering a sedative (choice A) may worsen respiratory depression. Performing a complete physical assessment (choice B) is important but not the priority in an emergency situation. Initiating chest physiotherapy (choice D) can be beneficial but is not as immediate as providing oxygen and positioning.
Question 3 of 5
The nurse teaches a patient about incentive spirometer use post-surgery. Which statement indicates further teaching is needed?
Correct Answer: C
Rationale: The correct answer is C. Exhaling into the device does not clear the lungs; the incentive spirometer is used for inhaling to improve lung function. A is correct as using the spirometer hourly promotes lung expansion. B is incorrect as the device measures inspired volume, not lung capacity. D is correct as using the spirometer helps prevent lung complications. In summary, option C is incorrect because exhaling into the device does not serve the intended purpose of the incentive spirometer, which is to promote deep inhalation.
Question 4 of 5
The nurse evaluates a patient after thoracentesis. Which finding should be reported immediately?
Correct Answer: C
Rationale: The correct answer is C: Tracheal deviation to the unaffected side. Tracheal deviation indicates a potential tension pneumothorax, a life-threatening emergency that requires immediate intervention. The trachea shifts away from the affected lung due to increased pressure, compromising air exchange. Reporting this finding promptly is crucial to prevent respiratory distress and cardiac compromise. Choices A and D are not immediate concerns post-thoracentesis. Mild discomfort and drainage amount are expected after the procedure. Choice B, a respiratory rate of 24 breaths per minute, falls within the normal range and may not warrant immediate attention.
Question 5 of 5
A patient is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). What is the nurse's priority intervention?
Correct Answer: D
Rationale: The correct answer is D: Position the patient prone as ordered. This is the priority intervention for a patient with ARDS because it helps improve oxygenation by optimizing ventilation-perfusion matching. Prone positioning can also reduce the risk of ventilator-associated lung injury. Administering diuretics (choice A) may be necessary for fluid management in ARDS, but it is not the priority intervention. Maintaining mechanical ventilation settings (choice B) is important, but positioning the patient prone takes precedence. Monitoring oxygen saturation and ABG changes (choice C) is also vital, but prone positioning should be the immediate priority to improve oxygenation.