ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 of 5
The nurse is monitoring a patient after a bronchoscopy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B: Oxygen saturation of 89%. A low oxygen saturation level of 89% indicates hypoxemia and requires immediate intervention to prevent complications like tissue damage or organ failure. Oxygen is essential for cellular function, and a saturation below 90% is concerning. Coughing with blood-tinged sputum (A) is common post-bronchoscopy. Hoarseness and sore throat (C) are expected due to the procedure. Mild chest discomfort (D) is also common post-bronchoscopy and may not require immediate intervention.
Question 2 of 5
The nurse observes an air leak in the water-seal chamber of a patient's chest tube. What is the best action?
Correct Answer: C
Rationale: The correct answer is C: Assess the system for loose connections or dislodgment. This is the best action because identifying the cause of the air leak is crucial before taking any further steps. Clamping the chest tube (A) can lead to tension pneumothorax. Notifying the healthcare provider (B) is important but does not address the immediate need to assess the system. Increasing suction (D) can worsen the situation if the cause of the air leak is not resolved. Overall, assessing the system first ensures proper management and prevents potential complications.
Question 3 of 5
Which intervention is most important when caring for a patient with a pulmonary embolism (PE)?
Correct Answer: B
Rationale: Correct Answer: B - Administer anticoagulant therapy as prescribed. Rationale: 1. Anticoagulant therapy helps prevent further clot formation in the lungs. 2. It helps dissolve existing clots and improve blood flow. 3. This intervention is crucial in managing and treating pulmonary embolism effectively. Summary: - A: Placing the patient in a supine position may worsen the condition by reducing blood flow to the lungs. - C: Deep breathing exercises are beneficial, but anticoagulant therapy takes precedence. - D: Restricting fluid intake is not a priority in the management of a pulmonary embolism.
Question 4 of 5
What is the priority nursing action for a patient presenting with possible pulmonary embolism?
Correct Answer: B
Rationale: The correct answer is B because applying oxygen and elevating the head of the bed will help improve oxygenation and reduce the workload on the heart. This is crucial in a patient with possible pulmonary embolism to prevent further complications. Administering anticoagulants (A) is important but not the priority as oxygenation takes precedence. Chest x-ray (C) can help confirm diagnosis but is not immediate. Notifying the healthcare provider (D) is important but not as urgent as ensuring adequate oxygenation.
Question 5 of 5
The nurse is teaching a patient with pneumonia about effective airway clearance. What instruction is most appropriate?
Correct Answer: A
Rationale: The correct answer is A: Increase fluid intake to thin mucus. Adequate hydration helps to thin mucus, making it easier to clear from the airways. This promotes effective airway clearance in patients with pneumonia. Incorrect choices: B: Using a peak flow meter is more relevant for monitoring asthma and not directly related to airway clearance in pneumonia. C: Limiting physical activity can lead to decreased lung function and impaired mucus clearance. D: Avoiding coughing can worsen pneumonia by allowing mucus to accumulate in the airways, leading to infection and further respiratory complications.