ATI RN
NCLEX Style Questions on Oxygenation Questions
Question 1 of 5
The nurse assesses a patient with a thoracotomy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B because chest tube drainage of 200 mL in the first hour after thoracotomy indicates active bleeding or a significant air leak, requiring immediate intervention to prevent complications like tension pneumothorax or hemorrhage. A: Oxygen saturation of 91% is concerning but not immediately life-threatening. C: Subcutaneous emphysema is expected post-thoracotomy and may not require immediate intervention. D: Diminished breath sounds may indicate a complication but are not as urgent as significant chest tube drainage.
Question 2 of 5
Which assessment finding in a patient with pneumonia is most concerning?
Correct Answer: B
Rationale: The correct answer is B: Oxygen saturation of 86% on room air. This finding is most concerning in a patient with pneumonia because it indicates severe hypoxemia, which can lead to tissue damage and organ failure. Low oxygen saturation levels can be life-threatening and require immediate intervention. Rationale: 1. Oxygen saturation is a direct indicator of how well the lungs are oxygenating the blood. 2. A saturation level of 86% on room air is significantly below the normal range (typically 95-100%). 3. Hypoxemia can lead to tissue hypoxia, organ dysfunction, and even respiratory failure if left untreated. 4. Prompt oxygen therapy is necessary to improve oxygenation and prevent further complications. Summary: A: Respiratory rate of 24 breaths per minute - Elevated respiratory rate is common in pneumonia but not as concerning as severe hypoxemia. C: Fever of 100.4°F (38°C) - Fever is a common symptom of pneumonia but
Question 3 of 5
The nurse assesses a patient with pneumonia and notes confusion. What is the most likely cause?
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia. Confusion in a patient with pneumonia is most likely due to lack of oxygen reaching the brain, which is caused by hypoxemia. When the lungs are infected, they are less able to oxygenate the blood, leading to hypoxemia. High fever (A) may cause delirium but is not the primary reason for confusion in pneumonia. Dehydration (C) can lead to confusion but is less likely in a patient with pneumonia. Sepsis (D) can cause confusion but is usually associated with other symptoms like low blood pressure and organ dysfunction.
Question 4 of 5
A nurse is assessing a patient with suspected tuberculosis. What is the priority diagnostic test?
Correct Answer: B
Rationale: The correct answer is B: Sputum culture. The priority diagnostic test for suspected tuberculosis is sputum culture because it directly identifies the presence of Mycobacterium tuberculosis. This test helps confirm the diagnosis and determine the appropriate treatment. Chest x-ray (A) is important but may not definitively diagnose TB. Mantoux test (C) checks for exposure but not active infection. Complete blood count (D) can show signs of infection but does not confirm TB.
Question 5 of 5
The nurse is caring for a patient with newly diagnosed pulmonary embolism (PE). What is the priority nursing intervention?
Correct Answer: A
Rationale: The priority nursing intervention for a patient with newly diagnosed pulmonary embolism (PE) is to administer prescribed anticoagulants (Choice A). This is because anticoagulants help to prevent further clot formation and reduce the risk of complications such as worsening of the PE or development of additional blood clots. Administering anticoagulants promptly is crucial in managing PE and improving outcomes for the patient. Positioning the patient supine and applying oxygen (Choice B) may be important, but it is not the priority over administering anticoagulants. Preparing for chest x-ray and CT scan (Choice C) and starting IV fluids (Choice D) are important assessments and interventions but are not the priority in the immediate management of PE.