ATI RN
NCLEX Oxygenation Practice Questions Questions
Question 1 of 5
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
Correct Answer: B
Rationale: The correct answer is B) UAP help splint the patient's chest during coughing. This action is incorrect because splinting the chest during coughing can restrict chest expansion, making it harder for the patient to effectively clear secretions from the lungs, which is crucial in pneumonia. Option A is correct as assisting the patient to ambulate to the bathroom promotes mobility and can help prevent complications associated with immobility. Option C is also correct as transferring the patient to a bedside chair for meals encourages activity and promotes a sense of normalcy. Option D is correct as lowering the head of the bed to 15 degrees helps improve oxygenation by reducing the risk of aspiration. Educationally, understanding the importance of proper respiratory care in pneumonia is vital for nurses and UAP to prevent complications and promote optimal patient outcomes. It is essential to reinforce the principles of chest physiotherapy and positioning techniques to support effective airway clearance in patients with respiratory conditions like pneumonia.
Question 2 of 5
A nurse is caring for a patient who is recovering from surgery. What is the priority intervention to prevent complications?
Correct Answer: C
Rationale: The correct answer is C) Encourage deep breathing exercises. The priority intervention for a patient recovering from surgery is to prevent complications such as atelectasis and pneumonia by promoting optimal lung expansion and gas exchange. Deep breathing exercises help prevent respiratory complications by improving lung ventilation and preventing the collapse of alveoli. This intervention also promotes oxygenation and aids in preventing the formation of respiratory secretions that can lead to respiratory infections. Option A) Administer pain medications may be necessary for the patient's comfort but is not the priority in preventing respiratory complications. Option B) Administer an inhaler may be indicated for patients with respiratory conditions such as asthma but is not the priority in preventing postoperative complications related to oxygenation. Option D) Administer a nebulized corticosteroid may be used for patients with specific respiratory conditions but is not the priority in preventing general postoperative respiratory complications. Educational Context: Understanding the importance of proper oxygenation and respiratory care in postoperative patients is crucial for nurses to provide optimal care and prevent complications. Encouraging deep breathing exercises is a fundamental nursing intervention to promote lung expansion, prevent atelectasis, and maintain adequate oxygenation levels in patients recovering from surgery.
Question 3 of 5
A nurse is caring for a patient with a history of myocardial infarction (MI). What is the priority action?
Correct Answer: A
Rationale: In this scenario, the priority action for a patient with a history of myocardial infarction (MI) is to administer aspirin (Option A). Aspirin is crucial in this situation because it helps prevent further clot formation by inhibiting platelet aggregation, thus reducing the risk of subsequent cardiac events. Administering oxygen therapy (Option B) may be important in some cases of MI to ensure adequate oxygenation, but in this specific situation, addressing the underlying cause of the MI is the priority. Administering short-acting bronchodilators (Option C) is more relevant in managing respiratory conditions like asthma or COPD, not in the immediate care of a patient with MI. Administering pain relief (Option D) is important but not the priority over aspirin, which directly addresses the pathophysiology of MI. Educationally, understanding the rationale behind prioritizing interventions in a patient with MI is essential for nurses preparing for the NCLEX exam. It tests the ability to prioritize care based on the patient's condition and the urgency of interventions to achieve optimal outcomes. This question highlights the critical thinking skills necessary for providing safe and effective care to patients with cardiovascular conditions.
Question 4 of 5
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient is experiencing shortness of breath. What is the priority intervention?
Correct Answer: A
Rationale: The priority intervention for a patient with COPD experiencing shortness of breath is to administer oxygen therapy (Option A). This is because in COPD, the patient's ability to adequately oxygenate their blood is compromised due to airway obstruction and decreased lung function. Providing supplemental oxygen helps improve oxygenation and relieves the symptoms of hypoxia, such as shortness of breath, which can be life-threatening. Administering corticosteroids (Option B) may be beneficial in reducing airway inflammation in COPD, but it is not the immediate priority when the patient is experiencing acute shortness of breath. Nebulized bronchodilators (Option C) can help dilate the airways and improve airflow, but addressing oxygenation is crucial in this acute situation. Administering insulin (Option D) is not indicated for the management of shortness of breath in a patient with COPD. In an educational context, it is important for nurses to prioritize interventions based on the patient's immediate needs and the urgency of the situation. Understanding the pathophysiology of COPD and the rationale behind interventions such as oxygen therapy is essential for providing safe and effective care to patients with respiratory conditions.
Question 5 of 5
The nurse observes that a patient with respiratory disease experiences a decrease in SpO₂ from 93% to 88% while the patient is ambulating. What is the priority action of the nurse?
Correct Answer: B
Rationale: The correct answer is B) Administer PRN supplemental O₂. Rationale: In this scenario, the priority action of the nurse is to administer supplemental oxygen to the patient experiencing a decrease in SpO₂ levels while ambulating. A drop from 93% to 88% indicates hypoxemia, which can lead to serious complications such as tissue damage or organ failure. Administering supplemental oxygen helps to improve oxygenation and prevent further deterioration of the patient's condition. Option A) Notify the health care provider: While it is important to keep the healthcare provider informed, administering oxygen to correct hypoxemia is the immediate priority to ensure patient safety. Option C) Document the response to exercise: Documenting the response is essential for tracking the patient's progress, but it should not take precedence over addressing the immediate oxygenation needs of the patient. Option D) Encourage the patient to pace activity: While pacing activity can be beneficial for patients with respiratory disease, in this acute situation of decreased SpO₂ levels, administering supplemental oxygen is the more critical intervention to address the hypoxemia promptly. Educational context: Understanding how to prioritize interventions based on assessment findings is crucial for nurses, especially when caring for patients with respiratory diseases. Monitoring oxygenation levels and responding promptly to any signs of hypoxemia are essential nursing skills to ensure patient safety and prevent complications related to inadequate oxygenation. Administering supplemental oxygen is a common intervention used to address hypoxemia quickly and effectively in clinical practice.