ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Correct Answer: D
Rationale: The correct answer, D, is appropriate for delegation to unlicensed assistive personnel (UAP) because measuring induration at the site of an intradermal skin test is a task that is simple, non-invasive, and within the UAP scope of practice. It does not require specialized knowledge or interpretation, making it suitable for delegation. Option A, listening to a patient's lung sounds for wheezes or crackles, involves a higher level of skill and interpretation that should be done by a licensed healthcare provider. Option B, labeling specimens obtained during percutaneous lung biopsy, requires precision and accuracy to ensure proper specimen handling, which is beyond the scope of a UAP's responsibilities. Option C, instructing a patient about how to use home spirometry testing, involves patient education and requires a healthcare provider's expertise to ensure accurate instruction and understanding. In an educational context, understanding the delegation of tasks is crucial for providing safe and effective patient care. Nurses must be able to differentiate between tasks that can be delegated to UAPs and those that require the expertise of licensed healthcare providers. This knowledge ensures that patient care is delivered efficiently while maintaining quality and safety standards.
Question 2 of 5
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is to continue to monitor the collection device (Option B) because continuous bubbling in the suction-control chamber of a chest tube collection device is expected when the system is functioning properly. This bubbling indicates that suction is being applied and that the chest tube is effectively draining fluid or air from the patient's pleural space. It is essential for the nurse to understand the normal functioning of the chest tube drainage system to differentiate between expected and concerning findings. Adjusting the dial on the wall regulator (Option A) is not necessary in this situation because the bubbling indicates that the suction is working correctly. Documenting the presence of a large air leak (Option C) may lead to unnecessary alarm if the bubbling is due to the expected suction. Notifying the surgeon of a possible pneumothorax (Option D) is premature without further assessment or evidence of a complication. Educationally, understanding the rationale behind the expected findings in chest tube management is crucial for nurses caring for patients with thoracic surgeries. This knowledge ensures appropriate and timely interventions, prevents unnecessary actions that may disrupt patient care, and promotes safe and effective nursing practice in managing chest tubes and drainage systems. Nurses must be equipped with the knowledge and critical thinking skills to assess, interpret, and respond to chest tube drainage system findings accurately to provide optimal care for their patients.
Question 3 of 5
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
Correct Answer: D
Rationale: In this scenario, option D is the correct answer because using the incentive spirometer every hour or two during the day helps prevent atelectasis and pneumonia, which are common complications associated with rib fractures. The incentive spirometer encourages deep breathing, improving lung function and preventing respiratory complications. Option A is incorrect because while a rib binder can provide support and comfort, it does not directly address the respiratory complications that can arise from rib fractures. Option B is incorrect because taking shallow breaths can lead to atelectasis and impaired lung function. Option C is incorrect because pain management should be consistent and not restricted to bedtime only. Effective pain control is crucial for promoting deep breathing, coughing, and mobility, all of which are essential for preventing respiratory complications in patients with rib fractures. Educationally, it is important for patients to understand the rationale behind using the incentive spirometer to prevent respiratory complications. By teaching patients the importance of deep breathing exercises and lung expansion techniques, nurses empower them to actively participate in their recovery and reduce the risk of complications. This educational context helps patients make informed decisions about their care and promotes better outcomes.
Question 4 of 5
The nurse develops a teaching plan to help increase activity tolerance at home for an older adult with severe chronic obstructive pulmonary disease (COPD). Which instructions would be appropriate for the nurse to include in the plan of care?
Correct Answer: D
Rationale: The correct answer, option D, is the most appropriate instruction for the older adult with severe COPD to increase activity tolerance at home. Walking for 15 to 20 minutes a day at least 3 times a week promotes gradual and safe progression in physical activity, helping to improve endurance without overexertion. This recommendation aligns with the principles of pulmonary rehabilitation for COPD patients, which emphasize regular, moderate exercise to enhance functional capacity and reduce symptoms. Option A is incorrect because stopping exercise when feeling short of breath may lead to avoidance of physical activity, hindering progress in improving activity tolerance. Option B is incorrect as exceeding a pulse rate of 130 beats/minute can indicate overexertion, which is not safe for individuals with COPD and can worsen symptoms. Option C is also incorrect as limiting exercise to activities of daily living may not provide enough physical activity to effectively increase activity tolerance in this population. Educationally, it is crucial for nurses to understand the principles of exercise prescription for patients with COPD to optimize their respiratory function and quality of life. By providing tailored instructions like walking for 15 to 20 minutes a day, nurses can empower patients to engage in safe and effective physical activity, promoting better management of their condition and overall well-being.
Question 5 of 5
Which finding in a patient hospitalized with bronchiectasis is most important to report to the health care provider?
Correct Answer: A
Rationale: The correct answer is option A) Cough productive of bloody, purulent mucus. This finding is the most important to report because hemoptysis (bloody mucus) in a patient with bronchiectasis can indicate a serious complication such as vessel erosion, which could lead to significant bleeding and compromised oxygenation. This symptom requires immediate attention and intervention to prevent further complications. Option B) Scattered crackles and wheezes heard bilaterally are common in bronchiectasis due to the presence of mucus in the airways. While these findings are important to note, they are not as urgent or indicative of a potentially life-threatening complication as hemoptysis. Option C) Complaint of sharp chest pain with deep breathing could indicate pleuritic pain, which is common in respiratory conditions. While this symptom should not be ignored, it is not as critical as hemoptysis in bronchiectasis. Option D) Respiratory rate of 28 breaths/minute while ambulating is elevated, but in bronchiectasis, patients may exhibit increased respiratory rates due to the chronic nature of the disease. While this finding should be monitored and managed, it is not as concerning as hemoptysis, which requires immediate attention. Educationally, it is crucial for nurses and healthcare providers to understand the significance of recognizing and prioritizing symptoms in patients with respiratory conditions like bronchiectasis. This question highlights the importance of prompt assessment and intervention in identifying potentially life-threatening complications, such as hemoptysis, to ensure patient safety and optimal outcomes.