ATI RN
NCLEX Oxygenation Practice Questions Questions
Question 1 of 5
The nurse assesses a patient with a chest tube and observes continuous bubbling in the water-seal chamber. What does this indicate?
Correct Answer: B
Rationale: Rationale: The correct answer is B) There is an air leak in the system. Continuous bubbling in the water-seal chamber of a chest tube indicates an air leak in the system. This can lead to ineffective lung re-expansion as the negative pressure required for proper drainage is compromised. Addressing the air leak promptly is crucial to prevent complications such as pneumothorax. Option A) The chest tube is functioning properly is incorrect because continuous bubbling indicates an issue in the system, not proper function. Option C) Suction pressure is too high is incorrect as high suction pressure would typically lead to excessive bubbling, not continuous bubbling. Option D) The patient has a pneumothorax is incorrect as continuous bubbling in the water-seal chamber does not directly indicate a pneumothorax but rather an air leak in the system. Understanding chest tube management is essential for nurses caring for patients with respiratory issues. Recognizing and addressing complications promptly is crucial for patient safety and optimal outcomes.
Question 2 of 5
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Correct Answer: C
Rationale: The correct answer is C) "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." This action is most effective in improving compliance with discharge teaching for a patient with COPD. Taking Tylenol for chest wall pain indicates that the patient is managing their discomfort, which can be a common symptom of COPD exacerbation. By addressing the pain, the patient is more likely to engage in activities and breathing exercises that are crucial for improving lung function and overall health. This response demonstrates the patient's understanding of self-care and symptom management, essential components of COPD management. Options A, B, and D all mention increased albuterol inhaler use, which may indicate worsening symptoms. While it is important for the nurse to address this, the primary focus should be on managing chest wall pain as it can impact the patient's ability to participate in necessary self-care activities and hinder compliance with discharge instructions. In an educational context, this question highlights the importance of holistic care for patients with COPD. It emphasizes the need to address not only respiratory symptoms but also pain management to improve patient outcomes and adherence to treatment plans. Understanding the rationale behind the correct answer reinforces the significance of comprehensive assessment and individualized care in nursing practice.
Question 3 of 5
A patient is experiencing nausea and vomiting following surgery. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: In this scenario, the correct intervention for a patient experiencing nausea and vomiting post-surgery is to apply a cold compress (Option C). This intervention helps to alleviate symptoms by providing comfort and reducing nausea through the application of cold to the forehead or back of the neck. Providing antiemetic medications (Option A) may be necessary in some cases, but addressing the discomfort and cooling effect of a cold compress should be the initial priority. Offering oral hydration (Option B) is important, but addressing the nausea and vomiting with a cold compress takes precedence. Encouraging deep breathing exercises (Option D) is beneficial for respiratory function but does not directly address the immediate symptoms of nausea and vomiting. Educationally, understanding the rationale behind prioritizing interventions based on immediate patient needs is crucial for nursing practice. It teaches students to prioritize care based on assessment findings and to address the most pressing issues first to ensure patient comfort and well-being. It also highlights the importance of quick thinking and appropriate intervention selection in emergency situations.
Question 4 of 5
A patient with a history of diabetes is admitted with diabetic ketoacidosis (DKA). What should the nurse do first?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Administer IV fluids and insulin. In a patient with diabetic ketoacidosis (DKA), the priority is to address the severe dehydration and electrolyte imbalances by administering IV fluids. Insulin therapy is also crucial to reverse the ketosis and hyperglycemia seen in DKA. Option B) Administer insulin alone is incorrect because without addressing the dehydration with IV fluids, the insulin therapy alone may worsen the dehydration and electrolyte imbalances. Option C) Administer a long-acting insulin is incorrect as immediate-acting insulin is needed to address the acute hyperglycemia in DKA. Option D) Administer a platelet aggregation inhibitor is unrelated to the immediate management of DKA and does not address the underlying pathophysiology. Educational Context: Understanding the priority interventions in managing DKA is essential for nurses caring for patients with diabetes. Administering IV fluids and insulin promptly can stabilize the patient's condition and prevent severe complications. This question highlights the critical thinking needed in emergency situations to prioritize care effectively.
Question 5 of 5
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
Correct Answer: B
Rationale: The correct answer is B) UAP help splint the patient's chest during coughing. This action is incorrect because splinting the chest during coughing can restrict chest expansion, making it harder for the patient to effectively clear secretions from the lungs, which is crucial in pneumonia. Option A is correct as assisting the patient to ambulate to the bathroom promotes mobility and can help prevent complications associated with immobility. Option C is also correct as transferring the patient to a bedside chair for meals encourages activity and promotes a sense of normalcy. Option D is correct as lowering the head of the bed to 15 degrees helps improve oxygenation by reducing the risk of aspiration. Educationally, understanding the importance of proper respiratory care in pneumonia is vital for nurses and UAP to prevent complications and promote optimal patient outcomes. It is essential to reinforce the principles of chest physiotherapy and positioning techniques to support effective airway clearance in patients with respiratory conditions like pneumonia.