ATI RN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
The RN is instructing the unlicensed assistive personnel (UAP) regarding the care of a male client with COPD. What is the highest priority nursing action to share with the UAP?
Correct Answer: B
Rationale: The correct answer is B: Keep the head of the bed elevated to 45 degrees. This is the highest priority action because it helps improve ventilation and oxygenation in clients with COPD by reducing the work of breathing and preventing respiratory complications. Elevating the head of the bed also helps prevent aspiration and promotes comfort. Choice A is incorrect because while ambulation is important, maintaining proper positioning for respiratory function is the priority in COPD. Choice C is incorrect as it does not address the immediate physiological needs of the client's respiratory status. Choice D is incorrect as it is a general task and not specific to managing COPD symptoms.
Question 2 of 5
The nurse assesses a patient with pneumonia who is experiencing pleuritic chest pain. Which action should the nurse take?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Placing the patient in a side-lying position on the affected side helps improve lung expansion and ventilation in the affected area, reducing pleuritic chest pain. 2. This position can also help prevent pooling of secretions and potential complications like atelectasis. 3. Encouraging shallow breaths (Choice A) may worsen the patient's condition by leading to decreased lung expansion. 4. Administering morphine (Choice C) may mask the pain but does not address the underlying cause or promote lung expansion. 5. Incentive spirometry (Choice D) is beneficial for preventing atelectasis but may not provide immediate relief for pleuritic chest pain.
Question 3 of 5
A patient with pulmonary embolism is receiving anticoagulant therapy. Which lab result should the nurse monitor to evaluate treatment effectiveness?
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time/international normalized ratio (PT/INR). PT/INR measures the clotting ability of the blood and is used to monitor the effectiveness of anticoagulant therapy. In patients with pulmonary embolism, the goal is to prevent further clot formation. Monitoring PT/INR helps adjust anticoagulant dosage to maintain therapeutic levels and prevent bleeding or clotting complications. Incorrect Choices: A: CBC provides information about red and white blood cells, not directly related to anticoagulant therapy monitoring. C: Serum creatinine is used to assess kidney function, not specifically related to anticoagulant therapy monitoring. D: Electrolyte levels are important for overall health, but not directly related to monitoring anticoagulant therapy effectiveness.
Question 4 of 5
The nurse teaches a patient how to minimize exposure to others while being treated for tuberculosis (TB). Which statement by the patient indicates a need for further teaching?
Correct Answer: C
Rationale: The correct answer is C because the patient should continue wearing a mask even after symptoms improve to prevent the spread of TB. Step 1: Wearing a mask helps minimize airborne transmission. Step 2: Discontinuing mask prematurely increases infection risk. Step 3: Options A, B, and D are correct as they promote isolation, ventilation, and precautions during the contagious period.
Question 5 of 5
The nurse observes bubbling in the water-seal chamber of a chest tube drainage system. What is the nurse's best action?
Correct Answer: C
Rationale: The correct action is to check the system for air leaks (Option C) because bubbling in the water-seal chamber indicates air is leaking into the system, which can compromise the chest tube's function. By identifying and addressing the air leak, the nurse can ensure proper drainage and prevent complications. Clamping the chest tube (Option A) can lead to tension pneumothorax. Increasing suction (Option B) can worsen the problem. Notifying the healthcare provider (Option D) should be done after checking for air leaks.