ATI RN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
The nurse would expect a patient with right-sided heart failure to have which of the following?
Correct Answer: A
Rationale: The correct answer is A: Peripheral edema. In right-sided heart failure, the right side of the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid backup in the venous system. This results in increased pressure in the peripheral veins, leading to fluid leakage into the surrounding tissues, causing peripheral edema. Basilar crackles (B) are associated with left-sided heart failure due to pulmonary congestion. Chest pain (C) is not typically a primary symptom of right-sided heart failure. Cyanosis (D) is usually seen in advanced stages of heart failure when oxygen saturation is severely compromised and is not specific to right-sided heart failure.
Question 2 of 5
Which client should the medical unit nurse assess first after receiving shift report?
Correct Answer: A
Rationale: The correct answer is A because the elderly client with pneumonia getting restless may indicate a change in condition or potential complications, requiring immediate assessment. Restlessness can be a sign of decreased oxygenation or sepsis in pneumonia patients. Choice B is incorrect as a headache in a young adult with influenza is not typically an immediate priority compared to potential respiratory distress in the elderly client. Choice C is incorrect as tidaling in the chest drainage system is expected and does not necessarily require immediate assessment unless other signs of distress are present. Choice D is incorrect as green drainage from the nose in a client with a sinus infection may indicate a bacterial infection but is not typically an urgent concern compared to potential acute respiratory compromise in the elderly client with pneumonia.
Question 3 of 5
The nurse is evaluating the effectiveness of oxygen therapy in a client with hypoxemia. Which finding indicates improvement?
Correct Answer: B
Rationale: The correct answer is B because an increase in oxygen saturation from 88% to 95% indicates improved oxygenation in the blood, reflecting the effectiveness of oxygen therapy. This improvement directly addresses the underlying issue of hypoxemia. A: Respiratory rate decreasing may indicate improvement, but it is not as specific to oxygenation as oxygen saturation levels. C: Heart rate decreasing could be a sign of improvement, but it is not as directly related to oxygen therapy effectiveness as oxygen saturation levels. D: Client reporting reduced fatigue is subjective and may not always correlate with objective improvement in oxygenation levels.
Question 4 of 5
A client with a tracheostomy is at risk for aspiration. What intervention should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Position the client in high Fowler's position during meals. This helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the tracheostomy. Keeping the client NPO (A) is not necessary unless directed by a healthcare provider. Suctioning the tracheostomy frequently (C) can increase the risk of infection and is only done when there is visible secretions. Providing thickened liquids (D) may still pose a risk of aspiration, so positioning is more effective in preventing this complication.
Question 5 of 5
The nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which intervention is most likely to improve oxygenation?
Correct Answer: B
Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position helps improve oxygenation in ARDS by optimizing ventilation-perfusion matching, reducing ventilation-perfusion mismatch, and improving lung mechanics. This position allows for better distribution of ventilation to the dorsal lung regions, improving oxygenation. Increasing oxygen flow rate (A) may not address the underlying issue of ventilation-perfusion mismatch. Performing frequent oral suctioning (C) is important for airway clearance but may not directly improve oxygenation. Administering a bronchodilator (D) may help in conditions like asthma but is not typically used in ARDS where the primary issue is not bronchoconstriction.