ATI RN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
The nurse is caring for a client with ARDS on mechanical ventilation. What is the priority assessment?
Correct Answer: A
Rationale: The correct answer is A: Ensuring proper endotracheal tube placement. This is the priority assessment because an improperly placed tube can lead to inadequate oxygenation or ventilation. Steps to ensure proper placement include assessing breath sounds, chest rise, and tube position on chest X-ray. Checking for pressure ulcers (B) is important but not the priority. Assessing for ventilator-associated pneumonia (C) and monitoring for signs of respiratory alkalosis (D) are important but secondary to ensuring proper tube placement for adequate oxygenation and ventilation.
Question 2 of 5
The RN is instructing the unlicensed assistive personnel (UAP) regarding the care of a male client with COPD. What is the highest priority nursing action to share with the UAP?
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 45 degrees. This is the highest priority action because it helps improve ventilation and oxygenation in clients with COPD by reducing the work of breathing and preventing respiratory complications. Elevating the head of the bed also helps prevent aspiration and promotes comfort. Choice A is incorrect because while ambulation is important, maintaining proper positioning for respiratory function is the priority in COPD. Choice C is incorrect as it does not address the immediate physiological needs of the client's respiratory status. Choice D is incorrect as it is a general task and not specific to managing COPD symptoms.
Question 3 of 5
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?
Correct Answer: A
Rationale: The correct answer is A because an increased respiratory rate of 36 breaths/min in a patient with COPD and worsening dyspnea can indicate respiratory distress or impending respiratory failure. This finding is crucial to report promptly to the healthcare provider for further evaluation and intervention. Choice B is incorrect because an anterior-posterior chest ratio of 1:1 is within normal limits and not directly related to the patient's current respiratory distress. Choice C is incorrect as decreased lung expansion bilaterally can be expected in a patient with COPD and may not necessarily warrant immediate concern unless it is significantly asymmetric or accompanied by other concerning signs. Choice D is incorrect as hyperresonance to percussion may be a typical finding in COPD due to increased lung volumes and is not an immediate priority compared to the elevated respiratory rate.
Question 4 of 5
The nurse assesses a patient with pneumonia who is experiencing pleuritic chest pain. Which action should the nurse take?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Placing the patient in a side-lying position on the affected side helps improve lung expansion and ventilation in the affected area, reducing pleuritic chest pain. 2. This position can also help prevent pooling of secretions and potential complications like atelectasis. 3. Encouraging shallow breaths (Choice A) may worsen the patient's condition by leading to decreased lung expansion. 4. Administering morphine (Choice C) may mask the pain but does not address the underlying cause or promote lung expansion. 5. Incentive spirometry (Choice D) is beneficial for preventing atelectasis but may not provide immediate relief for pleuritic chest pain.
Question 5 of 5
A patient with pulmonary embolism is receiving anticoagulant therapy. Which lab result should the nurse monitor to evaluate treatment effectiveness?
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time/international normalized ratio (PT/INR). PT/INR measures the clotting ability of the blood and is used to monitor the effectiveness of anticoagulant therapy. In patients with pulmonary embolism, the goal is to prevent further clot formation. Monitoring PT/INR helps adjust anticoagulant dosage to maintain therapeutic levels and prevent bleeding or clotting complications. Incorrect Choices: A: CBC provides information about red and white blood cells, not directly related to anticoagulant therapy monitoring. C: Serum creatinine is used to assess kidney function, not specifically related to anticoagulant therapy monitoring. D: Electrolyte levels are important for overall health, but not directly related to monitoring anticoagulant therapy effectiveness.