ATI RN
Oxygenation NCLEX Questions Questions
Question 1 of 5
The nurse assesses a patient with chest trauma and notes paradoxical chest movement. What is the nurse's priority action?
Correct Answer: C
Rationale: Rationale: 1. Paradoxical chest movement indicates a serious condition like flail chest, causing impaired breathing. 2. Oxygen therapy is the priority to ensure adequate oxygenation and prevent respiratory distress. 3. Administering pain medication may mask symptoms and delay appropriate intervention. 4. Chest tube insertion may be needed but is not the immediate priority. 5. Positioning the patient on the affected side is not recommended as it can worsen respiratory distress. Summary: Oxygen therapy is crucial to address respiratory compromise in chest trauma with paradoxical chest movement, while other options may not directly address the underlying issue or could potentially delay appropriate care.
Question 2 of 5
A patient recovering from a thoracotomy has no chest tube drainage for 2 hours. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B: Assess the chest tube for kinks or obstructions. This is the first step because if there are any kinks or obstructions in the chest tube, it could lead to inadequate drainage and potentially cause complications such as pneumothorax or hemothorax. Repositioning the patient (choice A) may be necessary after ensuring the chest tube is functioning properly. Notifying the healthcare provider (choice C) should be done after assessing the chest tube. Increasing suction pressure (choice D) without assessing for kinks or obstructions may worsen the situation.
Question 3 of 5
A patient reports severe chest pain and difficulty breathing after a thoracentesis. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C because reassessing vital signs and oxygen saturation is crucial to determine the patient's current status and the severity of the symptoms. This step allows the nurse to quickly identify any potential complications or deterioration in the patient's condition. Administering analgesic (choice A) may temporarily alleviate pain but does not address the underlying issue. Notifying the healthcare provider (choice B) is important but should not delay immediate assessment and intervention. Positioning the patient on the affected side (choice D) is not appropriate in this scenario and may worsen the symptoms.
Question 4 of 5
A patient with acute asthma exacerbation reports worsening symptoms despite frequent inhaler use. What should the nurse prioritize?
Correct Answer: B
Rationale: Correct Answer: B (Reassess the patient's peak expiratory flow) Rationale: Reassessing the peak expiratory flow is crucial to determine the severity of the asthma exacerbation and guide further treatment. It helps assess lung function and response to therapy, aiding in adjusting the treatment plan promptly. This step is essential in managing acute asthma exacerbations effectively. Administering systemic corticosteroids (choice A) is important but should follow proper assessment. Teaching about triggers (choice C) is beneficial but not the priority during an exacerbation. Notifying the healthcare provider (choice D) can be done after reassessment.
Question 5 of 5
The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Auscultate anterior and posterior breath sounds bilaterally. This is the next appropriate action after noting absent fremitus during palpation of the posterior chest. Auscultation helps assess breath sounds and detects abnormalities such as wheezing or crackles. It provides valuable information about the patient's lung health and can help identify potential respiratory issues. Palpating the anterior chest or observing for barrel chest (choice A) is not the immediate priority when fremitus is absent. Encouraging the patient to turn, cough, and deep breathe (choice B) may be beneficial but does not directly address the absence of fremitus. Reviewing the chest x-ray report for evidence of pneumonia (choice C) is important but does not address the immediate need to further assess breath sounds in this scenario.