ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
The nurse is caring for a patient with a tracheostomy who has thick secretions. Which action is most appropriate?
Correct Answer: A
Rationale: The correct answer is A: Perform tracheostomy suctioning using sterile technique. This is the most appropriate action because thick secretions can obstruct the tracheostomy tube, leading to respiratory distress. Suctioning helps clear the airway and maintain patency. Sterile technique is crucial to prevent introducing infection. Incorrect Choices: B: Increasing oxygen flow does not directly address the issue of thick secretions in the tracheostomy tube. C: Instilling normal saline may further increase secretions and can potentially cause aspiration. D: Encouraging the patient to take deep breaths may not effectively clear the thick secretions from the tracheostomy tube.
Question 2 of 5
The nurse is preparing a patient with suspected pulmonary embolism for diagnostic tests. Which test should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B: Spiral CT scan. This test is the priority for diagnosing pulmonary embolism as it provides quick and accurate visualization of blood flow in the lungs. Chest x-ray (A) may not show definitive signs of embolism. Pulmonary function test (C) measures lung function but does not directly diagnose embolism. Arterial blood gas analysis (D) may show respiratory status but does not confirm the presence of embolism. Spiral CT scan is the gold standard for diagnosing pulmonary embolism due to its high sensitivity and specificity.
Question 3 of 5
A patient with asthma reports increased use of a rescue inhaler. What is the nurse's priority intervention?
Correct Answer: C
Rationale: The correct answer is C: Perform a peak expiratory flow reading. This is the priority intervention because it helps assess the severity of the patient's asthma exacerbation objectively. By measuring the peak expiratory flow, the nurse can determine the degree of airflow limitation and response to treatment. This information guides appropriate interventions and helps in monitoring the effectiveness of the treatment. Notification of the healthcare provider (choice A) can be important but assessing the patient's respiratory status takes precedence. Teaching proper inhaler technique (choice B) and assessing adherence to maintenance medication (choice D) are important interventions but not the immediate priority when the patient is experiencing increased symptoms.
Question 4 of 5
A patient with tuberculosis is started on isoniazid. What should the nurse monitor for?
Correct Answer: B
Rationale: The correct answer is B: Peripheral neuropathy symptoms. Isoniazid can lead to peripheral neuropathy due to vitamin B6 deficiency. The nurse should monitor for numbness, tingling, or weakness in extremities. Signs of hepatotoxicity (choice A) are associated with other TB medications. Orange discoloration of body fluids (choice C) is a side effect of rifampin. Changes in visual acuity (choice D) are not typically associated with isoniazid.
Question 5 of 5
A patient with a tracheostomy tube exhibits difficulty breathing and thick secretions. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B - Perform tracheal suctioning. This action helps clear the thick secretions that are causing difficulty breathing. Tracheal suctioning is necessary for patients with tracheostomy tubes to maintain a clear airway. Encouraging deep breathing and coughing (choice A) may not be effective in clearing thick secretions from the trachea. Administering a bronchodilator (choice C) may help with bronchospasm but does not address the underlying issue of thick secretions. Repositioning the patient (choice D) may provide some relief but does not directly address the problem of airway obstruction due to thick secretions.