ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
The nurse knows that a closed suction device would be most appropriate for which patient?
Correct Answer: D
Rationale: The correct answer is D because a closed suction device is typically used for patients with respiratory issues like aspiration pneumonia as it helps to clear secretions effectively. For a 75-year-old with aspiration pneumonia following a stroke, maintaining airway patency and clearing secretions are crucial for preventing complications. Choices A, B, and C do not specifically require closed suction devices as their conditions do not primarily involve the need for airway clearance through suctioning.
Question 2 of 5
The nurse is assessing a patient with emphysema. Which clinical finding is consistent with this condition?
Correct Answer: C
Rationale: The correct answer is C: Barrel-shaped chest. In emphysema, the chronic destruction of alveoli leads to loss of lung elasticity, causing the chest to become hyperinflated and take on a barrel shape. This is due to air trapping in the lungs. A: Frequent productive cough is commonly seen in conditions like chronic bronchitis, not specific to emphysema. B: Cyanosis of lips and fingertips indicates poor oxygenation, which is more commonly associated with conditions like pneumonia or acute respiratory distress. D: Peripheral edema is a sign of fluid retention and heart failure, not typically seen in emphysema.
Question 3 of 5
A client with asthma is admitted for an acute exacerbation. Which medication should the nurse administer first?
Correct Answer: A
Rationale: The correct answer is A: Short-acting beta2-agonist. During an acute asthma exacerbation, bronchodilation is the priority to relieve airway constriction and improve breathing. Short-acting beta2-agonists like albuterol act quickly to relax bronchial smooth muscles, providing immediate relief. This medication is the first-line treatment for acute exacerbations as it addresses the underlying bronchoconstriction. Inhaled corticosteroids (B) are used for long-term management and prevention of asthma symptoms, not for immediate relief. Leukotriene receptor antagonists (C) are typically used as adjunct therapy and not for acute exacerbations. Long-acting beta2-agonists (D) are used for maintenance therapy and should not be used as the initial treatment during an acute exacerbation.
Question 4 of 5
A client with COPD reports fatigue during activities of daily living. What intervention should the nurse recommend?
Correct Answer: C
Rationale: The correct answer is C: Rest between activities to conserve energy. This intervention is appropriate for a client with COPD experiencing fatigue as it helps prevent overexertion and conserves energy. Resting between activities allows the client to pace themselves, reducing the risk of worsening symptoms. Performing all activities in the morning (choice A) may not address the fatigue throughout the day. Using oxygen only during strenuous activities (choice B) does not address the underlying issue of energy conservation. Increasing activity level to build endurance (choice D) may lead to further fatigue and exacerbate symptoms. Overall, choice C is the most suitable intervention for managing fatigue in a client with COPD.
Question 5 of 5
A client recovering from a thoracentesis reports feeling lightheaded and short of breath. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Assess the client for signs of pneumothorax. Following a thoracentesis, lightheadedness and shortness of breath could indicate a pneumothorax, a potential complication where air accumulates in the pleural space. The priority action is to assess for signs of pneumothorax, such as decreased breath sounds, chest pain, and respiratory distress, as it requires immediate intervention to prevent further complications. Encouraging slow, deep breaths (A) may worsen a pneumothorax. Administering pain medication (C) is not the priority when respiratory distress is present. Positioning the client flat (D) may exacerbate a pneumothorax.