ATI RN
Oxygen NCLEX Questions Questions
Question 1 of 5
The nurse observes continuous bubbling in the water-seal chamber of a chest tube. What is the next step?
Correct Answer: C
Rationale: The correct next step is to check for air leaks in the system (Choice C). Continuous bubbling in the water-seal chamber indicates an air leak. By checking for air leaks, the nurse can identify and address the source of the problem, ensuring the chest tube is functioning properly. Clamping the tube (Choice A) can lead to tension pneumothorax. Notifying the healthcare provider (Choice B) should be done after assessing and addressing immediate issues. Adding water to the chamber (Choice D) is incorrect as it can disrupt the water seal and lead to further issues.
Question 2 of 5
A patient reports shortness of breath and left-sided chest pain. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B because assessing oxygen saturation and vital signs is crucial in determining the patient's current status and severity of the symptoms. This step provides immediate information on the patient's respiratory status and guides further interventions. Administering oxygen (A) without assessing the patient's oxygen saturation may not address the underlying issue. While a chest x-ray (C) may be necessary, it is not the immediate priority. Notifying the healthcare provider (D) can be done after assessing the patient's vital signs. Thus, choice B is the priority to ensure prompt and appropriate care for the patient.
Question 3 of 5
A patient with influenza has a persistent high fever and worsening cough. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B because reassessing lung sounds for signs of pneumonia is crucial in a patient with worsening cough as it can indicate a possible complication of influenza. Pneumonia can lead to respiratory distress and requires immediate intervention. Administering antipyretics (A) may address the fever but does not address the underlying issue. Encouraging increased fluid intake (C) and providing supportive care (D) are important but do not address the immediate risk of pneumonia in this case.
Question 4 of 5
A patient with COPD is admitted for increasing dyspnea. Which finding requires the nurse's immediate attention?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation of 84% on room air. This finding requires immediate attention because a saturation below 90% indicates severe hypoxemia in a COPD patient, putting them at risk of respiratory failure. Oxygen therapy is needed urgently to improve oxygenation. B: Respiratory rate of 22 breaths per minute is within the normal range and does not indicate immediate distress. C: Productive cough with green sputum may suggest an infection but does not require immediate attention unless accompanied by other severe symptoms. D: Bilateral wheezes can be common in COPD and indicate airflow obstruction but do not necessitate immediate intervention unless the patient's condition worsens rapidly.
Question 5 of 5
A patient admitted to the emergency department complaining of sudden onset shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
Correct Answer: B
Rationale: The correct answer is B because starting an IV line allows for contrast media administration, which is crucial for diagnostic testing like a CT pulmonary angiography to confirm pulmonary embolism. Contrast media helps visualize blood vessels and detect blockages. Choice A (NPO) is unnecessary for this test. Choice C (radioactive glucose) is not used for pulmonary embolus diagnosis. Choice D (sedatives) would not be appropriate as the patient needs to be alert during the test.