ATI RN
Oxygen Therapy Questions and Answers Questions
Question 1 of 5
The nurse evaluates a patient with a chest tube. Which finding requires immediate action?
Correct Answer: A
Rationale: In the context of oxygen therapy and chest tube management, the correct answer to the question is option A) Continuous bubbling in the water-seal chamber. This finding requires immediate action because it indicates an air leak, which can compromise the effectiveness of the chest tube drainage system and lead to potentially serious complications such as pneumothorax. Option B) Drainage of 60 mL in the past hour is within the expected range for chest tube drainage and does not necessarily warrant immediate action unless there are other concerning signs or symptoms present. Option C) Dressing dry and intact at the insertion site is a positive finding indicating proper wound care and does not require immediate action. Option D) Tidaling observed in the water-seal chamber is a normal finding and indicates proper functioning of the chest tube drainage system. Educationally, understanding the significance of each finding in chest tube management is crucial for nurses caring for patients requiring oxygen therapy. Recognizing abnormal findings and knowing when to take immediate action is essential to prevent complications and ensure optimal patient outcomes. Regular monitoring and assessment of chest tube systems are vital components of nursing care in respiratory and critical care settings.
Question 2 of 5
A patient reports frequent nosebleeds. Which initial action by the nurse is most appropriate?
Correct Answer: B
Rationale: In this scenario, selecting option B, instructing the patient to lean forward and pinch the nostrils, is the most appropriate initial action by the nurse when a patient reports frequent nosebleeds. This approach helps to apply direct pressure to the source of bleeding and promotes clot formation to stop the bleeding effectively. Option A, applying a cold compress to the back of the neck, is not the most appropriate initial action for nosebleeds because direct pressure at the source of bleeding is crucial to stop the flow of blood. Option C, inserting nasal packing to stop the bleeding, is an invasive intervention that should be reserved for severe or uncontrolled nosebleeds after initial measures have failed. It is not the first-line action. Option D, encouraging the patient to lie down and rest, is not the best initial response to nosebleeds. While rest is important, the immediate focus should be on stopping the bleeding using direct pressure as described in option B. Educationally, it is important for nurses to understand the sequential approach to managing nosebleeds, starting with simple, non-invasive techniques like direct pressure. This helps prevent unnecessary escalation of interventions and ensures appropriate and timely care for patients experiencing this common issue.
Question 3 of 5
Which assessment finding in a patient with pneumonia requires immediate action?
Correct Answer: C
Rationale: In this scenario, the correct answer is option C: Oxygen saturation of 84% on room air. This finding requires immediate action because it indicates severe hypoxemia, which can lead to serious complications such as organ damage and respiratory failure. Oxygen saturation below 90% is considered low and requires intervention to prevent further deterioration of the patient's condition. Option A (Temperature of 101.3°F) may be indicative of infection but does not require immediate action as it is not life-threatening in the same way as severe hypoxemia. Option B (Productive cough with yellow sputum) is common in pneumonia but does not indicate an immediate need for intervention. Option D (Coarse crackles heard in the lung bases) may suggest fluid in the lungs but does not require immediate action as addressing hypoxemia is the priority in this case. Educationally, this question highlights the importance of recognizing and prioritizing critical assessment findings in patients with respiratory conditions. Understanding the significance of oxygen saturation levels and the potential consequences of severe hypoxemia is crucial for healthcare providers to deliver prompt and effective care to patients in respiratory distress.
Question 4 of 5
A patient reports coughing up blood and severe chest pain. What is the nurse's first action?
Correct Answer: A
Rationale: In this scenario, the correct answer is to position the patient in a semi-Fowler's position (Option A) as the first action. Placing the patient in a semi-Fowler's position helps improve oxygenation and facilitates breathing by reducing pressure on the chest and promoting lung expansion. This position also helps in relieving chest pain and can aid in the management of hemoptysis (coughing up blood). Notifying the healthcare provider immediately (Option B) is important, but the immediate action should be to address the patient's comfort and oxygenation first. Administering oxygen at 2 L/min (Option C) could be beneficial, but without knowing the underlying cause of the symptoms, it may not be the most appropriate initial action. Performing a respiratory assessment (Option D) is important but should come after ensuring the patient's immediate comfort and safety. In an educational context, this question highlights the importance of prioritizing interventions based on the patient's presenting symptoms. It emphasizes the significance of assessing and addressing urgent needs promptly to ensure patient safety and well-being. Understanding the rationale behind the correct action helps nurses develop critical thinking skills and clinical judgment in emergency situations.
Question 5 of 5
A patient with COPD reports worsening shortness of breath. What should the nurse assess first?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Oxygen saturation levels. When a patient with COPD experiences worsening shortness of breath, assessing oxygen saturation levels is critical because hypoxemia can significantly impact their condition. Low oxygen saturation levels can indicate respiratory distress and the need for supplemental oxygen therapy to improve oxygenation and alleviate symptoms. Option A) Respiratory rate and effort is important in assessing respiratory status, but in a patient with COPD experiencing worsening shortness of breath, checking oxygen saturation levels takes precedence as it provides more immediate information about oxygen exchange. Option C) Lung sounds for wheezing or crackles are important in assessing respiratory conditions, but in this case, the priority is to determine the oxygenation status of the patient. Option D) Peak expiratory flow rate is more commonly used in conditions like asthma to monitor airway obstruction, and it is not the first assessment to perform in a COPD patient with worsening shortness of breath. Educationally, understanding the prioritization of assessments in patients with COPD is crucial for nurses and healthcare providers to effectively manage and intervene in respiratory distress situations. By recognizing the significance of assessing oxygen saturation levels promptly, healthcare professionals can make timely interventions to improve patient outcomes and prevent respiratory complications.