ATI RN
NCLEX Style Questions on Oxygenation Questions
Question 1 of 5
The nurse notes a large air leak in the chest tube system of a patient with a pneumothorax. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C: Check all connections for leaks. The priority action is to identify and address the source of the air leak to prevent complications such as tension pneumothorax. Clamping the chest tube (A) can lead to a life-threatening situation. Notifying the healthcare provider (B) is important but not the immediate action. Repositioning the chest tube (D) does not address the air leak issue. Checking all connections for leaks (C) ensures the integrity of the chest tube system and allows for prompt intervention.
Question 2 of 5
A nurse is caring for a patient with chronic kidney disease (CKD). Which intervention should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administer diuretics. In CKD, the kidneys are unable to effectively remove waste and excess fluid from the body. Diuretics help to manage fluid overload by increasing urine output. This can help prevent complications such as edema and fluid overload. Increasing fluid intake (choice B) would worsen fluid overload. Providing a warm compress to the foot (choice C) is not a priority in CKD. Administering a platelet inhibitor (choice D) is not directly related to managing CKD.
Question 3 of 5
A nurse is caring for a patient with a history of hypertension. The patient is experiencing a hypertensive crisis. What is the priority intervention?
Correct Answer: C
Rationale: The priority intervention for a patient experiencing a hypertensive crisis is to reduce blood pressure gradually to prevent complications like stroke or heart attack. Encouraging deep breathing exercises helps lower blood pressure by promoting relaxation and reducing stress. Administering antihypertensive medication or nitroglycerin may cause a sudden drop in blood pressure, leading to hypoperfusion of vital organs. Thrombolytic therapy is not indicated for hypertensive crisis. Deep breathing exercises are a safe and effective first-line intervention to manage the hypertensive crisis.
Question 4 of 5
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Positioning only on the right side. This is the first action the nurse should take because it helps improve ventilation-perfusion matching and oxygenation post-thoracotomy. By positioning the patient on the right side, gravity helps to optimize lung expansion on the unaffected side, improving gas exchange. Option A may be uncomfortable for the patient and not directly address the underlying issue. Option B is important but not the first priority in this scenario. Option D is also essential but positioning on the right side takes precedence in addressing the patient's immediate needs.
Question 5 of 5
A nurse is caring for a patient with a history of asthma who is complaining of chest tightness and wheezing. What is the priority intervention?
Correct Answer: B
Rationale: The correct answer is B: Notify the healthcare provider. The priority intervention is to inform the healthcare provider because the patient is experiencing worsening symptoms of asthma, which may require immediate medical attention or a change in treatment plan. Administering a bronchodilator (choice A) can help relieve symptoms, but it is not the priority when the patient's condition is deteriorating. Encouraging deep breathing exercises (choice C) may not be effective in managing acute asthma exacerbation. Administering a sedative (choice D) is not appropriate and can worsen respiratory distress. Overall, notifying the healthcare provider ensures timely assessment and appropriate intervention for the patient's worsening condition.