ATI RN
NCLEX Style Questions Oxygenation Questions
Question 1 of 5
The nurse is caring for a client post-thoracentesis. Which finding requires immediate intervention?
Correct Answer: C
Rationale: In this scenario, option C, "Tracheal deviation to the unaffected side," requires immediate intervention. Tracheal deviation is a critical sign that can indicate tension pneumothorax, a life-threatening emergency where air accumulates in the pleural space under pressure, pushing the mediastinum and trachea to the unaffected side. This compromises cardiac output and can lead to respiratory failure and cardiac arrest. Option A, "Oxygen saturation of 95%," is within the expected range and does not indicate an immediate concern. Option B, "Respiratory rate of 16 breaths per minute," is also within the normal range for an adult and does not signal an urgent issue. Option D, "Mild discomfort at the procedure site," is common after thoracentesis and can be managed with pain relief measures. It does not require immediate intervention unless it worsens or is accompanied by other concerning symptoms. Educationally, it is crucial for nurses to recognize and respond promptly to signs of respiratory distress post-thoracentesis to prevent complications. Understanding the significance of tracheal deviation and differentiating it from expected post-procedure discomfort is vital in providing safe and effective care to patients undergoing thoracentesis.
Question 2 of 5
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
Correct Answer: D
Rationale: The correct answer is D) Sitting upright with the arms supported on an over-bed table. For a thoracentesis procedure in a patient with a left-sided pleural effusion, positioning the patient sitting upright allows for better access to the pleural space and easier visualization for the healthcare provider performing the procedure. This position helps maximize lung expansion, making it easier to access the pleural effusion. Option A) High-Fowler's position with the left arm extended is incorrect as it does not provide optimal positioning for accessing the pleural effusion on the left side. Option B) Supine with the head of the bed elevated 30 degrees is incorrect because lying flat does not facilitate access to the pleural space. Option C) On the right side with the left arm extended above the head is incorrect as it does not provide the best positioning for accessing the pleural effusion on the left side and may cause discomfort to the patient. In an educational context, understanding the correct positioning for thoracentesis is crucial for providing safe and effective patient care. Proper positioning can impact the success and safety of the procedure, so nurses must be knowledgeable about the rationale behind positioning choices for various patient conditions.
Question 3 of 5
A patient hospitalized with community-acquired pneumonia has a temperature of 101.6° F, a frequent cough, and severe pleuritic chest pain. Which prescribed medication should the nurse give first?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Piperacillin/tazobactam (Zosyn). When a patient with community-acquired pneumonia presents with a high fever, severe chest pain, and cough, these symptoms indicate a potentially serious infection that requires prompt antibiotic therapy. Piperacillin/tazobactam is a broad-spectrum antibiotic that covers a wide range of pathogens commonly associated with pneumonia, making it the priority medication to address the underlying infection. The other options are not the best choices in this situation: A) Codeine: Codeine is a cough suppressant and would not address the underlying infection causing the pneumonia. B) Guaifenesin: Guaifenesin is an expectorant used to help loosen mucus in the airways but would not treat the infection. C) Acetaminophen (Tylenol): Acetaminophen is a fever reducer and pain reliever, which may provide symptomatic relief but does not address the infection itself. In an educational context, this question highlights the importance of prioritizing patient care based on assessment findings and understanding the rationale behind the prescribed treatments. Nurses need to recognize the urgency of treating infections like pneumonia promptly to prevent complications and improve patient outcomes. This question also emphasizes the need for nurses to have a strong foundation in pharmacology to make appropriate medication decisions in acute care settings.
Question 4 of 5
A patient presents with nasal trauma and clear drainage. What is the nurse's priority action?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Test the drainage for glucose. The priority action for a patient presenting with nasal trauma and clear drainage is to assess for the presence of cerebrospinal fluid (CSF) leakage, which can occur due to trauma to the skull base. Testing the drainage for glucose can help differentiate between CSF leakage (which would contain glucose) and nasal mucus or other fluids. Identifying CSF leakage is crucial as it can lead to serious complications such as meningitis if left untreated. Option A) Apply an ice pack to reduce swelling is incorrect because while it may help with swelling, it is not the priority when assessing for a potentially serious condition like CSF leakage. Option C) Insert nasal packing to control bleeding is also incorrect because the priority is to first determine if the clear drainage is CSF, as nasal packing could increase intracranial pressure if CSF is present. Option D) Keep the patient in a supine position is incorrect as it does not address the immediate need to assess for CSF leakage. In an educational context, this question highlights the importance of clinical assessment and critical thinking in nursing practice. Nurses must be able to prioritize actions based on the patient's condition and the potential for serious complications. Understanding the significance of assessing for CSF leakage in cases of nasal trauma is crucial for providing safe and effective care to patients.
Question 5 of 5
The nurse teaches a patient with a new diagnosis of asthma how to use a peak flow meter. Which statement by the patient indicates effective learning?
Correct Answer: A
Rationale: The correct answer is option A: "I will blow into the meter as hard and fast as possible." This statement indicates effective learning because using a peak flow meter requires the patient to forcefully exhale to get an accurate reading of their peak expiratory flow rate, which is crucial in monitoring asthma symptoms and determining the effectiveness of treatment. Option B is incorrect because inhaling deeply before exhaling into the peak flow meter can affect the accuracy of the reading. The patient should exhale normally and forcefully to obtain the correct measurement. Option C is incorrect because peak flow meters are used for regular monitoring of asthma symptoms, not just when the patient feels short of breath. Regular use helps in identifying early signs of worsening asthma and adjusting treatment accordingly. Option D is incorrect because holding the breath after using the peak flow meter is not necessary and does not contribute to obtaining an accurate reading. It is important for the patient to exhale forcefully into the meter and then record the value without holding their breath. In an educational context, it is vital for patients with asthma to understand how to correctly use a peak flow meter to monitor their lung function. By providing clear instructions and ensuring that patients demonstrate the correct technique, nurses can empower patients to actively manage their asthma and seek timely medical intervention when necessary.