ATI RN
Chapter 41 Oxygenation NCLEX 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 is the nurse's next action?
Correct Answer: C
Rationale: The correct next action is to assess the system for an air leak. This is because continuous bubbling in the water-seal chamber indicates air is escaping from the patient's chest cavity through the tube. By assessing the system for an air leak, the nurse can identify and address the source of the problem. Clamping the chest tube (choice A) can lead to a tension pneumothorax and is not appropriate. Adding more water (choice B) is incorrect as it will not address the underlying issue. Replacing the entire system (choice D) is unnecessary without first identifying the specific problem.
Question 2 of 5
Which intervention is most important when caring for a patient with a pulmonary embolism (PE)?
Correct Answer: B
Rationale: Correct Answer: B - Administer anticoagulant therapy as prescribed. Rationale: 1. Anticoagulant therapy helps prevent further clot formation in the lungs. 2. It helps dissolve existing clots and improve blood flow. 3. This intervention is crucial in managing and treating pulmonary embolism effectively. Summary: - A: Placing the patient in a supine position may worsen the condition by reducing blood flow to the lungs. - C: Deep breathing exercises are beneficial, but anticoagulant therapy takes precedence. - D: Restricting fluid intake is not a priority in the management of a pulmonary embolism.
Question 3 of 5
What is the priority nursing action for a patient presenting with possible pulmonary embolism?
Correct Answer: B
Rationale: The correct answer is B because applying oxygen and elevating the head of the bed will help improve oxygenation and reduce the workload on the heart. This is crucial in a patient with possible pulmonary embolism to prevent further complications. Administering anticoagulants (A) is important but not the priority as oxygenation takes precedence. Chest x-ray (C) can help confirm diagnosis but is not immediate. Notifying the healthcare provider (D) is important but not as urgent as ensuring adequate oxygenation.
Question 4 of 5
The nurse is teaching a patient with pneumonia about effective airway clearance. What instruction is most appropriate?
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake to thin mucus. Adequate hydration helps to thin mucus, making it easier to clear from the airways. This promotes effective airway clearance in patients with pneumonia. Incorrect choices: B: Using a peak flow meter is more relevant for monitoring asthma and not directly related to airway clearance in pneumonia. C: Limiting physical activity can lead to decreased lung function and impaired mucus clearance. D: Avoiding coughing can worsen pneumonia by allowing mucus to accumulate in the airways, leading to infection and further respiratory complications.
Question 5 of 5
A patient with an acute asthma attack is using an albuterol inhaler frequently. What is the nurse's best action?
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's technique for inhaler use. This is crucial because improper inhaler technique can lead to ineffective medication delivery. By assessing the technique, the nurse can ensure the patient is using the inhaler correctly to optimize treatment efficacy. Providing education on spacer devices (B) may be beneficial, but assessing the current technique should be the initial step. Notifying the healthcare provider for additional treatment options (C) is premature without first assessing the current technique. Teaching the patient to use the inhaler only as needed (D) does not address the core issue of proper technique.