ATI RN
Oxygen Therapy NCLEX Questions Questions
Question 1 of 5
The nurse is caring for a client with cystic fibrosis. What intervention is most effective in improving airway clearance?
Correct Answer: B
Rationale: The correct answer is B: Performing chest physiotherapy regularly. Chest physiotherapy helps mobilize and clear mucus from the airways in cystic fibrosis patients, improving airway clearance. This intervention is essential in preventing respiratory complications. Administering bronchodilators before meals (A) may help with bronchodilation but does not directly address airway clearance. Providing a high-calorie, high-protein diet (C) is important for nutrition but does not specifically target airway clearance. Encouraging the use of a spacer with inhalers (D) may help with medication delivery but does not directly improve airway clearance like chest physiotherapy.
Question 2 of 5
A client with tuberculosis (TB) is prescribed rifampin. Which side effect should the nurse include in client education?
Correct Answer: A
Rationale: The correct answer is A: Orange discoloration of urine and tears. Rifampin is known to cause harmless orange discoloration of bodily fluids, including urine and tears. This is important for the client to be aware of to prevent unnecessary concern. B: Increased risk of photosensitivity is not a common side effect of rifampin. C: Frequent urination is not a typical side effect of rifampin. D: Sudden weight gain is not a known side effect of rifampin. In conclusion, the correct answer is A because it aligns with a known side effect of rifampin, while the other options are not associated with this medication.
Question 3 of 5
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
Correct Answer: C
Rationale: The correct answer is C: Discontinuous, high-pitched sounds of short duration during inspiration. In heart failure, the patient may develop pulmonary edema leading to crackles or fine rales on auscultation, which are best heard during inspiration due to the opening of collapsed alveoli. This is characterized by short-duration, high-pitched sounds. Option A is more indicative of rhonchi, commonly heard in conditions like bronchitis. Option B describes wheezes typically found in asthma or COPD. Option D describes coarse crackles, which are heard in conditions like pneumonia. Therefore, the most likely finding in a patient with early heart failure would be discontinuous, high-pitched sounds during inspiration.
Question 4 of 5
Which intervention will the nurse include in the plan of care for a patient diagnosed with a lung abscess?
Correct Answer: B
Rationale: The correct answer is B: Assist the patient with chest physiotherapy and postural drainage. This intervention helps mobilize secretions in the lungs, aiding in the drainage of the abscess. Chest physiotherapy can improve ventilation and oxygenation. A: Avoiding over-the-counter expectorants is not directly related to managing a lung abscess. They may not be effective for this condition. C: Notifying the healthcare provider about bloody or foul-smelling sputum is important, but it is not a direct intervention for managing a lung abscess. D: Teaching about the need for prolonged antibiotic therapy is important, but the immediate intervention for a lung abscess is to assist with chest physiotherapy and postural drainage to improve outcomes.
Question 5 of 5
A patient is admitted with acute respiratory distress syndrome (ARDS). Which assessment finding is most concerning?
Correct Answer: A
Rationale: The correct answer is A: SpO2 of 86% despite high-flow oxygen. This finding is most concerning as it indicates severe hypoxemia despite maximal oxygen therapy, which is a critical sign of ARDS. Hypoxemia is the main feature of ARDS and can rapidly lead to organ failure. Choice B (Respiratory rate of 24 breaths per minute) is within normal range and may not be as concerning in isolation. Choice C (Fine crackles in bilateral lung bases) is common in ARDS but may not necessarily indicate severity. Choice D (Heart rate of 102 beats per minute) is elevated but not as immediately life-threatening as severe hypoxemia.