ATI RN
Chapter 41 Oxygenation NCLEX Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A patient with an acute asthma attack is using an albuterol inhaler frequently. What is the nurse's best action?
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's technique for inhaler use. This is crucial because improper inhaler technique can lead to ineffective medication delivery. By assessing the technique, the nurse can ensure the patient is using the inhaler correctly to optimize treatment efficacy. Providing education on spacer devices (B) may be beneficial, but assessing the current technique should be the initial step. Notifying the healthcare provider for additional treatment options (C) is premature without first assessing the current technique. Teaching the patient to use the inhaler only as needed (D) does not address the core issue of proper technique.
Question 5 of 5
The nurse reviews arterial blood gas results for a patient with respiratory distress: pH 7.25, PaCO2 55 mm Hg, HCO3- 26 mEq/L. What is the interpretation?
Correct Answer: B
Rationale: The correct answer is B: Uncompensated respiratory acidosis. The low pH (acidosis) and high PaCO2 (respiratory component) indicate respiratory acidosis. The HCO3- level is within normal range, suggesting no metabolic compensation. Therefore, it is uncompensated respiratory acidosis. Option A is incorrect because the pH is not within the normal range, indicating partial compensation has not occurred. Option C is incorrect as the HCO3- level is normal, ruling out metabolic acidosis. Option D is incorrect because the patient's pH is acidic, not alkalotic.