ATI RN
NCLEX Style Questions on Oxygenation Questions
Question 1 of 5
The nurse is caring for a patient after a thoracentesis. Which finding requires immediate attention?
Correct Answer: B
Rationale: The correct answer is B, Oxygen saturation of 88%. A low oxygen saturation level of 88% indicates hypoxemia, which can be life-threatening and requires immediate attention to prevent complications like organ damage or respiratory failure. A: Mild discomfort at the puncture site is expected after a thoracentesis and can be managed with pain relief measures. C: Removing 300 mL of pleural fluid is a normal part of the procedure and does not require immediate attention unless signs of complications arise. D: A respiratory rate of 18 breaths per minute is within the normal range, so it does not require immediate attention. In summary, a low oxygen saturation level is the most critical finding that needs prompt intervention compared to the other choices.
Question 2 of 5
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
Correct Answer: C
Rationale: The correct answer is C. Keeping the windows closed at home helps prevent the spread of TB bacteria by reducing the circulation of contaminated air. This statement shows understanding of how TB is transmitted through the air. Explanation: A: Taking the bus instead of driving does not relate to TB transmission. B: Having the spouse sleep in another room may reduce transmission, but it does not address other potential sources. D: Staying indoors whenever possible does not address the risk of exposure to contaminated air inside the home.
Question 3 of 5
A nurse is caring for a patient with chronic kidney disease (CKD). Which intervention should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administer diuretics. In CKD, the kidneys are unable to effectively remove waste and excess fluid from the body. Diuretics help to manage fluid overload by increasing urine output. This can help prevent complications such as edema and fluid overload. Increasing fluid intake (choice B) would worsen fluid overload. Providing a warm compress to the foot (choice C) is not a priority in CKD. Administering a platelet inhibitor (choice D) is not directly related to managing CKD.
Question 4 of 5
A nurse is caring for a patient with a history of hypertension. The patient is experiencing a hypertensive crisis. What is the priority intervention?
Correct Answer: C
Rationale: The priority intervention for a patient experiencing a hypertensive crisis is to reduce blood pressure gradually to prevent complications like stroke or heart attack. Encouraging deep breathing exercises helps lower blood pressure by promoting relaxation and reducing stress. Administering antihypertensive medication or nitroglycerin may cause a sudden drop in blood pressure, leading to hypoperfusion of vital organs. Thrombolytic therapy is not indicated for hypertensive crisis. Deep breathing exercises are a safe and effective first-line intervention to manage the hypertensive crisis.
Question 5 of 5
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Positioning only on the right side. This is the first action the nurse should take because it helps improve ventilation-perfusion matching and oxygenation post-thoracotomy. By positioning the patient on the right side, gravity helps to optimize lung expansion on the unaffected side, improving gas exchange. Option A may be uncomfortable for the patient and not directly address the underlying issue. Option B is important but not the first priority in this scenario. Option D is also essential but positioning on the right side takes precedence in addressing the patient's immediate needs.