ATI RN
Oxygenation Nursing Practice Questions Questions
Question 1 of 5
The nurse observes continuous bubbling in the water-seal chamber of a patient's chest tube. What should the nurse do?
Correct Answer: B
Rationale: The correct answer is B: Check the system for air leaks. Continuous bubbling in the water-seal chamber indicates an air leak in the system. Checking for air leaks is important to prevent complications like pneumothorax. Clamping the chest tube (A) can cause tension pneumothorax. Adding more sterile water (C) can disrupt the system's balance. Notifying the healthcare provider (D) should be done after checking for air leaks.
Question 2 of 5
A patient with pneumonia reports sharp chest pain that worsens with deep breathing. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B because auscultating the lungs for breath sounds will help assess the severity and distribution of the pneumonia. This step is vital in determining the appropriate treatment and intervention. Administering pain reliever (Choice A) may mask symptoms and delay proper assessment. Encouraging deep breaths (Choice C) can exacerbate the pain. Placing the patient in a high Fowler's position (Choice D) may provide comfort but does not address the immediate need for assessment.
Question 3 of 5
A patient with tuberculosis is started on isoniazid (INH). What should the nurse monitor for?
Correct Answer: A
Rationale: The correct answer is A: Signs of peripheral neuropathy. Isoniazid can cause peripheral neuropathy due to vitamin B6 deficiency. The nurse should monitor for numbness, tingling, or weakness in extremities. Choices B, C, and D are incorrect because isoniazid does not typically cause hearing loss, visual disturbances, or hair thinning.
Question 4 of 5
Which action by the nurse would prevent ventilator-associated pneumonia (VAP)?
Correct Answer: C
Rationale: Certainly. The correct answer is C, providing oral care with chlorhexidine. This action helps reduce the risk of VAP by decreasing the oral bacterial load, preventing aspiration of pathogens into the lungs. Suctioning the airway every 2 hours (A) can irritate the airway and increase the risk of infection. Administering antibiotics prophylactically (B) can lead to antibiotic resistance and should be reserved for specific indications. Keeping the patient sedated (D) may increase the risk of aspiration due to reduced cough reflex.
Question 5 of 5
A patient with severe respiratory distress is admitted. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B because in a critical situation like severe respiratory distress, immediate actions are crucial. Asking focused questions about the current episode will provide essential information for quick decision-making and interventions. It helps in assessing the severity of the distress, identifying potential causes, and determining the appropriate initial treatment. Obtaining a comprehensive health history (choice A) can be important but not urgent in this acute situation. Delaying assessment for pulmonary function tests (choice C) can be detrimental as it can delay necessary interventions. Checking for allergies before treatment (choice D) is important but not the priority when the patient is in severe distress.