ATI RN
Nursing Fundamentals Oxygenation Questions Questions
Question 1 of 5
The nurse observes a patient with a tracheostomy coughing up thick secretions. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Perform tracheal suctioning. This is the first intervention because thick secretions can obstruct the tracheostomy tube, leading to respiratory distress. Suctioning helps clear the airway to improve breathing. Encouraging oral fluid intake (B) may not be effective in clearing the secretions. Administering a mucolytic agent (C) may help liquefy secretions but suctioning is more immediate. Teaching about humidification (D) can help prevent thick secretions but immediate action is needed to clear the airway.
Question 2 of 5
The nurse teaches a patient with asthma how to use a peak flow meter. Which statement indicates the need for additional instruction?
Correct Answer: B
Rationale: The correct answer is B because using the peak flow meter only when feeling short of breath may not provide an accurate assessment of lung function. The peak flow meter should be used regularly to monitor lung function, not just when symptoms are present. Option A is correct as exhaling forcefully ensures an accurate reading. Option C is correct as recording the highest reading is recommended for tracking progress. Option D is correct as using the meter before and after medications helps evaluate the effectiveness of treatment.
Question 3 of 5
A patient with COPD reports increased dyspnea. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Administer a prescribed bronchodilator. This is the first intervention because it helps to relieve bronchoconstriction and improve airflow, addressing the immediate symptom of dyspnea in COPD. Bronchodilators act quickly to open up the airways, providing prompt relief. B: Increasing oxygen flow rate may be necessary, but addressing bronchoconstriction with a bronchodilator should come first. C: Assessing arterial blood gases is important for evaluating oxygenation status, but administering a bronchodilator should be the initial action for immediate relief of dyspnea. D: Encouraging pursed-lip breathing is a helpful technique for managing dyspnea in COPD, but administering a bronchodilator is the priority to address the underlying bronchoconstriction causing the increased dyspnea.
Question 4 of 5
A patient with a chest tube has no drainage in the collection chamber for 2 hours. What is the nurse's best action?
Correct Answer: C
Rationale: The correct answer is C: Assess for kinks or obstructions in the tubing. This is the best action because lack of drainage in the collection chamber could indicate a blockage in the tubing, preventing proper drainage. By assessing for kinks or obstructions first, the nurse can identify and address the issue causing the lack of drainage. Repositioning the patient may not address the underlying problem, clamping the chest tube could cause a tension pneumothorax, and removing the chest tube without addressing the cause could lead to complications.
Question 5 of 5
Which nursing action is most important for preventing ventilator-associated pneumonia (VAP)?
Correct Answer: B
Rationale: The correct answer is B: Performing frequent oral care with chlorhexidine. This is crucial for preventing VAP as it helps reduce the colonization of bacteria in the oral cavity that can be aspirated into the lungs. Antibiotics (A) are not preventive measures for VAP. Turning the patient (C) helps prevent pressure ulcers, not VAP. Keeping the patient sedated (D) can lead to inadequate respiratory effort and increase the risk of VAP. Overall, proper oral care plays a significant role in reducing the risk of VAP by minimizing bacterial growth in the mouth.