ATI RN
NCLEX Practice Questions Oxygenation Questions
Question 1 of 5
The nurse is preparing to discharge a client with sleep apnea. Which intervention is most appropriate to include in the teaching plan?
Correct Answer: B
Rationale: Rationale: The correct answer is B) Lose weight if you are overweight. This is the most appropriate intervention because excess weight can contribute to the development or exacerbation of sleep apnea. By losing weight, the client can reduce the amount of soft tissue in the throat area that may block the airway during sleep, improving breathing patterns and reducing apnea episodes. Option A) Sleep on your back to maintain an open airway is incorrect as sleeping on the back can actually worsen sleep apnea by causing the tongue and soft tissues to collapse into the airway, leading to obstruction. Option C) Avoid using CPAP if symptoms improve is incorrect because CPAP (Continuous Positive Airway Pressure) is a common and effective treatment for sleep apnea. It helps keep the airway open during sleep by delivering a continuous flow of air through a mask. Option D) Limit fluid intake before bedtime is also incorrect as it may help reduce the frequency of nighttime awakenings to urinate, but it does not directly address the underlying issue of sleep apnea. In an educational context, teaching clients about the relationship between weight and sleep apnea is crucial. By understanding how weight can impact their condition, clients can make informed lifestyle changes to improve their symptoms and overall health. It is important for nurses to provide evidence-based education to empower clients in managing their sleep apnea effectively.
Question 2 of 5
A client with COPD is prescribed tiotropium (Spiriva). What should the nurse include in the teaching plan?
Correct Answer: B
Rationale: In the context of a client with COPD being prescribed tiotropium (Spiriva), option B, "This medication is used for long-term management, not quick relief," is the correct answer. This is because tiotropium is a long-acting bronchodilator that helps to manage COPD symptoms over time by improving lung function and reducing exacerbations. It is not meant for immediate relief of symptoms during exacerbations, as stated in option A. Option C, "Avoid eating grapefruit while taking this medication," is incorrect as there is no known interaction between tiotropium and grapefruit. Option D, "Take the medication with food to prevent stomach upset," is also incorrect as tiotropium is typically taken on an empty stomach. In an educational context, it is crucial for nurses to understand the rationale behind medication administration to provide effective patient education. By emphasizing that tiotropium is a long-term management medication, nurses can ensure that patients use it correctly to achieve optimal therapeutic outcomes in the management of COPD. This knowledge helps in promoting patient adherence and self-management in the long-term care of COPD.
Question 3 of 5
A client with pleural effusion is experiencing severe shortness of breath. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B) Prepare the client for a thoracentesis. In the context of a client with pleural effusion experiencing severe shortness of breath, a thoracentesis is the priority intervention to remove the accumulated fluid from the pleural space, relieving pressure on the lungs and improving oxygenation. This procedure can rapidly improve the client's breathing and oxygen levels, addressing the immediate respiratory distress. Option A) Position the client on the unaffected side may provide some comfort but does not address the underlying cause of the shortness of breath, which is the pleural effusion compromising lung expansion. Option C) Administer prescribed diuretics may be part of the treatment plan for managing pleural effusion in the long term by reducing fluid retention, but it is not the immediate priority in a client experiencing severe respiratory distress. Option D) Encouraging deep breathing exercises is not appropriate when the client is in severe respiratory distress due to pleural effusion. The priority is to relieve the pressure on the lungs through thoracentesis before focusing on breathing exercises. In an educational context, understanding the priority interventions for clients with respiratory conditions like pleural effusion is crucial for nurses to provide timely and effective care, especially in acute situations where respiratory compromise can quickly escalate. This question highlights the importance of critical thinking and prioritization in nursing practice, emphasizing the significance of addressing the root cause of respiratory distress to ensure optimal patient outcomes.
Question 4 of 5
A client with COPD is prescribed a corticosteroid inhaler. What teaching point should the nurse emphasize?
Correct Answer: B
Rationale: The correct answer is B) Rinse your mouth after each use. This teaching point is crucial for a client using a corticosteroid inhaler for COPD to prevent the development of oral thrush, a common side effect of inhaled corticosteroids. Rinsing the mouth helps to remove any medication residue that could lead to fungal overgrowth in the mouth. Option A) Use the inhaler only when symptoms worsen is incorrect because corticosteroid inhalers are typically used on a regular schedule to manage inflammation and prevent symptoms from worsening. Option C) Shake the inhaler only if symptoms persist is incorrect because corticosteroid inhalers need to be shaken before each use to ensure proper dispersion of the medication for effective delivery to the lungs. Option D) Use the inhaler before a bronchodilator is incorrect because bronchodilators are usually used first to help open the airways, followed by corticosteroid inhalers to reduce inflammation. In an educational context, it is essential for nurses to provide clear and accurate instructions on the use of inhalers to promote optimal therapeutic outcomes and prevent adverse effects. Teaching patients about proper inhaler technique and potential side effects empowers them to effectively manage their condition and improve their quality of life.
Question 5 of 5
The nurse is preparing to administer a nebulized bronchodilator to a client. Which assessment finding is most concerning?
Correct Answer: A
Rationale: In this scenario, option A, a heart rate of 115 beats per minute, is the most concerning assessment finding. The rationale behind this is that an elevated heart rate can indicate cardiac stress or overstimulation from the bronchodilator, potentially leading to cardiac complications. Option B, an oxygen saturation of 90%, while suboptimal, may be expected in a client receiving a bronchodilator for oxygenation issues. It is concerning but not as immediately critical as an elevated heart rate. Option C, a respiratory rate of 22 breaths per minute, is within normal range and does not immediately indicate a critical issue. Option D, the client reporting mild hand tremors, is a common side effect of bronchodilators and is not as concerning as the potential cardiac implications of an elevated heart rate. Educationally, understanding these assessment findings in the context of administering bronchodilators is crucial for nurses to ensure prompt recognition of potential complications and appropriate intervention to optimize patient outcomes. Nursing students preparing for the NCLEX need to grasp the prioritization of assessments to provide safe and effective care to clients receiving respiratory treatments.