ATI LPN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
The nurse is caring for a patient on a ventilator and reads the order "restrain prn." The nurse considers which factor when caring for this patient? (Select all that apply)
Correct Answer: C
Rationale: Safety restraint devices (SRDs) are used to protect patients but must be applied correctly to avoid harm. SRDs do not inherently decrease anxiety (A) and may increase it if misused. Not all older adults need SRDs at night (B) as this is not a blanket requirement and should be individualized. Allowing maximum freedom of movement (C) is correct to prevent injury and maintain comfort. Tying SRDs to side rails (D) is unsafe as it can cause injury if the rail moves; they should be tied to the bed frame. Ensuring two fingers can fit between the SRD.
Question 2 of 5
The client is experiencing severe shortness of breath,but is not cyanotic. What laboratory value should the nurse review in an attempt to understand this phenomenon?
Correct Answer: B
Rationale: Cyanosis requires at least 5 g/dL of unoxygenated hemoglobin and dilated surface capillaries. Severe anemia (low hemoglobin/hematocrit B) can prevent cyanosis despite hypoxia as insufficient hemoglobin limits visible deoxygenation. Blood sugar (A) cardiac enzymes (C) and electrolytes (D) do not explain the absence of cyanosis making B the relevant lab value to review.
Question 3 of 5
The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?
Correct Answer: C
Rationale: An oropharyngeal airway facilitates airflow but can stimulate secretions. Turning the head to the side (C) allows drainage of oral secretions preventing aspiration. Taping (A) is not standard as the airway is temporary. Suctioning (B) may be needed but is not the immediate action. A nasal trumpet (D) is a different device making C the appropriate action to ensure airway patency and safety.
Question 4 of 5
A client with a nasotracheal tube in place has been restless and pulling at the tube. How should the nurse assess if the tube is still in place?
Correct Answer: C
Rationale: The nasotracheal tube should sit above the tracheal bifurcation. Auscultating bilateral breath sounds (C) confirms correct placement as equal sounds indicate the tube is not dislodged or in a mainstem bronchus. Counting respirations (A) or assessing depth (B) does not verify tube position. Deflating the cuff (D) is unsafe and unnecessary making C the appropriate assessment method.
Question 5 of 5
A client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?
Correct Answer: D
Rationale: Bronchodilators and steroid inhalers can be used together with the bronchodilator typically first for immediate relief followed by the steroid for maintenance (A C incorrect). Steroids (B) are not for immediate effects as they reduce inflammation over time. Both medications (D) can increase heart rate a key side effect to monitor making D essential teaching for safety and compliance.