ATI RN
Oxygen Therapy NCLEX Questions Questions
Question 1 of 5
The nurse observes continuous bubbling in the water-seal chamber of a chest tube. What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Check for loose connections in the system. Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system. The nurse should first check for loose connections, as this is a common cause of air leaks. Clamping the chest tube (choice A) could lead to tension pneumothorax. Replacing the entire system (choice C) may not be necessary if the issue is a simple loose connection. Notifying the healthcare provider (choice D) can be done after checking for loose connections to provide an update on the situation.
Question 2 of 5
The nurse prepares a patient for a bronchoscopy. What is the most important pre-procedure instruction?
Correct Answer: A
Rationale: The correct answer is A: Avoid eating or drinking for 6-8 hours before the procedure. This instruction is crucial to prevent aspiration during bronchoscopy. Eating or drinking can lead to vomiting, which poses a risk during the procedure. Choice B is incorrect as some medications may need to be avoided before the procedure. Choice C is incorrect as chest discomfort is not expected during the procedure. Choice D is incorrect as deep breathing exercises are not typically required before bronchoscopy.
Question 3 of 5
Which intervention is most effective for preventing ventilator-associated pneumonia (VAP)?
Correct Answer: A
Rationale: The correct answer is A: Performing oral care with chlorhexidine. This intervention is most effective for preventing VAP because it helps reduce the colonization of pathogenic bacteria in the oral cavity, which can be aspirated into the lungs. Chlorhexidine is an antiseptic agent that can effectively reduce the risk of developing pneumonia. Summary of other choices: B: Changing ventilator tubing every shift - While maintaining clean ventilator tubing is important for infection prevention, it is not the most effective intervention for preventing VAP. C: Suctioning the patient hourly - Frequent suctioning may be necessary for airway clearance, but it is not specifically targeted at preventing VAP. D: Keeping the patient sedated continuously - Continuous sedation may lead to complications such as prolonged ventilation and increased risk of pneumonia. It is not a recommended strategy for preventing VAP.
Question 4 of 5
Which finding in a patient with respiratory distress requires the nurse's immediate intervention?
Correct Answer: A
Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound typically heard on inspiration, indicating upper airway obstruction. This finding requires immediate intervention as it can lead to airway compromise and respiratory distress. Explanation for why other choices are incorrect: B: Cough productive of yellow sputum may indicate a respiratory infection but does not necessarily require immediate intervention. C: Oxygen saturation of 92% on 2 L/min oxygen is concerning but not immediately life-threatening. It may require adjustment of oxygen therapy. D: Respiratory rate of 20 breaths per minute falls within the normal range and does not indicate immediate intervention is needed.
Question 5 of 5
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?
Correct Answer: C
Rationale: Rationale: Choice C is correct because hand washing should be performed not just before entering the room but also immediately upon leaving it to prevent the spread of TB. Hand hygiene is crucial in infection control. Choices A, B, and D are incorrect because offering a tissue, wearing a surgical mask, and bringing a snack do not pose a risk of spreading TB and are appropriate actions in caring for a patient with active TB.