ATI RN
NCLEX Questions on Oxygen Therapy Questions
Question 1 of 5
The nurse reviews arterial blood gas results: pH 7.30, PaCO2 55 mm Hg, HCO3- 24 mEq/L. What is the interpretation?
Correct Answer: B
Rationale: The correct interpretation is uncompensated respiratory acidosis (Choice B). Step-by-step rationale: 1. pH is low (acidosis): Indicates an acid-base imbalance. 2. PaCO2 is high (55 mm Hg): Indicates respiratory acidosis. 3. HCO3- is within normal range (24 mEq/L): Indicates no compensation by the kidneys. Therefore, the patient is experiencing respiratory acidosis without compensatory metabolic changes. Other choices are incorrect: A: Metabolic acidosis: HCO3- is within normal range. C: Partially compensated metabolic acidosis: PaCO2 is high, not low. D: Compensated respiratory alkalosis: pH is low, indicating acidosis.
Question 2 of 5
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
Correct Answer: C
Rationale: The correct answer is C because a decrease in white blood cell count indicates a reduction in infection. This is a key indicator of the effectiveness of antibiotic treatment for pneumonia. A: Bronchial breath sounds indicate consolidation, which is not necessarily indicative of improvement. B: Green mucus suggests ongoing infection rather than improvement. D: Increased tactile fremitus can be present in pneumonia and may not necessarily change with treatment efficacy.
Question 3 of 5
A nurse is caring for a patient with a history of stroke. What is the priority nursing intervention?
Correct Answer: B
Rationale: The correct answer is B: Monitor the patient for changes in neurological status. This is the priority intervention because patients with a history of stroke are at risk for complications such as recurrent strokes or worsening neurological status. Monitoring for changes allows for early detection and timely intervention. A: Assisting with a swallowing assessment is important, but monitoring neurological status takes precedence as it directly assesses the patient's brain function. C: Having a family member for rehabilitation is beneficial but not the priority over monitoring neurological status for immediate complications. D: Providing medication for swallowing improvement may be necessary, but monitoring neurological status is crucial for detecting any emergent issues. In summary, monitoring neurological status is the priority as it directly assesses the patient's brain function and allows for early detection of complications.
Question 4 of 5
A nurse is caring for a patient with severe burns. The patient is at risk for fluid volume deficit. What is the priority nursing action?
Correct Answer: A
Rationale: The correct answer is A. Administering intravenous fluids is the priority nursing action for a patient at risk for fluid volume deficit due to severe burns. This helps restore fluid balance and prevent complications like hypovolemic shock. Monitoring respiratory status (B) is important but not the priority in this case. Administering oral antibiotics (C) may be necessary but does not address the immediate risk of fluid deficit. Providing family support (D) is essential but not the priority when the patient's physiological needs must be addressed first.
Question 5 of 5
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B because a sudden onset of shortness of breath in a patient on bed rest may indicate a life-threatening condition like a pulmonary embolism or cardiac event. Assessing this patient first is crucial for prompt intervention. Choice A can wait as pulmonary function testing is a scheduled procedure. Choice C, the TB patient, can wait briefly as medications can be administered a bit later without immediate harm. Choice D, the patient with pneumonia and a low-grade fever, is stable and can be assessed after the patient with sudden shortness of breath.