ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
The nurse observes continuous bubbling in the water-seal chamber of a chest tube. What does this indicate?
Correct Answer: B
Rationale: The continuous bubbling in the water-seal chamber indicates an air leak in the system. When air leaks into the chest tube system, it creates bubbling in the water-seal chamber. This indicates that the system is not airtight, compromising its ability to remove air or fluid from the pleural space effectively. Choices A, C, and D are incorrect because continuous bubbling does not indicate proper functioning of the chest tube, presence of a pneumothorax, or high suction pressure.
Question 2 of 5
Which intervention should the nurse implement for a patient with a chest tube and continuous bubbling in the water-seal chamber?
Correct Answer: D
Rationale: The correct answer is D because checking all connections for a loose fitting is essential in this situation. This step ensures that there are no leaks or disconnections along the chest tube system, which could be causing the continuous bubbling in the water-seal chamber. Clamping the chest tube (Choice A) could lead to a tension pneumothorax and is not recommended. Notifying the healthcare provider of an air leak (Choice B) can be done after checking the connections. Repositioning the tubing (Choice C) may not address the underlying issue of a loose connection.
Question 3 of 5
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Correct Answer: C
Rationale: The correct answer is C: Arrange for the patient's caregiver to be present during the teaching. Rationale: 1. Involving the patient's caregiver promotes better understanding and support for the patient's care at home. 2. Caregivers can assist in reinforcing teaching, ensuring the patient follows instructions. 3. Caregivers can help monitor the patient for any signs of worsening condition or noncompliance. 4. This approach is effective in addressing potential barriers to compliance and continuity of care. Summary of other choices: A: Having the patient repeat instructions may not guarantee understanding or retention of information. B: Teaching just before discharge may not allow enough time for the patient and caregiver to fully grasp and prepare for home care. D: Starting teaching during admission may overwhelm the patient and may not address the need for ongoing support at home.
Question 4 of 5
A patient with asthma is being treated with corticosteroids. Which statement by the patient indicates the need for further education?
Correct Answer: A
Rationale: The correct answer is A because discontinuing corticosteroid therapy abruptly can lead to asthma exacerbation and potentially life-threatening consequences. Patients must not stop corticosteroids abruptly without consulting their healthcare provider. Choice B is incorrect as increasing the dose may be necessary under medical supervision. Choice C is incorrect as increasing the beta-agonist dose can be a part of asthma management. Choice D is incorrect as monitoring for signs of infection is a necessary precaution when on corticosteroid therapy.
Question 5 of 5
A patient is being admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing action?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy. In COPD exacerbation, there is inadequate oxygenation due to impaired lung function. Administering oxygen therapy is the priority to improve oxygen levels and prevent hypoxia. Oxygen therapy helps reduce the work of breathing and decrease the workload on the heart. It is crucial to address hypoxemia promptly to prevent further complications. Summary: - Option B: Administering a bronchodilator can help improve airflow but is not the priority in a COPD exacerbation. - Option C: Administering fluids and electrolytes may be needed, but oxygen therapy takes precedence in improving oxygenation. - Option D: Encouraging deep breathing exercises is beneficial but not as urgent as providing oxygen therapy to address hypoxemia.