ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
Which assessment finding in a patient with pneumonia requires the nurse to intervene immediately?
Correct Answer: C
Rationale: The correct answer is C because an oxygen saturation of 86% indicates severe hypoxemia, which can lead to tissue damage and organ dysfunction. The nurse should intervene immediately to improve oxygenation. A weak productive cough (Choice A) may indicate impaired airway clearance but does not require immediate intervention. Pleuritic chest pain (Choice B) is common in pneumonia but does not indicate an immediate threat to the patient's life. Coarse crackles in the lower lobes (Choice D) are typical findings in pneumonia but do not necessitate immediate action unless accompanied by severe respiratory distress.
Question 2 of 5
Which assessment finding is most concerning for a patient receiving treatment for pneumonia?
Correct Answer: B
Rationale: The correct answer is B: Oxygen saturation of 85%. This assessment finding is most concerning because it indicates severe hypoxemia, which can lead to tissue damage and respiratory failure. A low oxygen saturation level of 85% requires immediate intervention to prevent further complications. Rationale: 1. Crackles heard in the lung bases (Choice A) are common in pneumonia but do not indicate severe hypoxemia. 2. Cough with yellow sputum production (Choice C) is a common symptom of pneumonia but does not directly reflect the patient's oxygenation status. 3. Respiratory rate of 22 breaths per minute (Choice D) is within the normal range and may not necessarily indicate severe respiratory distress. In summary, the oxygen saturation of 85% is the most concerning assessment finding as it directly reflects the patient's oxygenation status and requires immediate attention to prevent complications.
Question 3 of 5
The nurse is preparing a patient with suspected pulmonary embolism for diagnostic tests. Which test should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is B: Spiral CT scan. This test is the priority for diagnosing pulmonary embolism as it provides quick and accurate visualization of blood flow in the lungs. Chest x-ray (A) may not show definitive signs of embolism. Pulmonary function test (C) measures lung function but does not directly diagnose embolism. Arterial blood gas analysis (D) may show respiratory status but does not confirm the presence of embolism. Spiral CT scan is the gold standard for diagnosing pulmonary embolism due to its high sensitivity and specificity.
Question 4 of 5
A patient with asthma reports increased use of a rescue inhaler. What is the nurse's priority intervention?
Correct Answer: C
Rationale: The correct answer is C: Perform a peak expiratory flow reading. This is the priority intervention because it helps assess the severity of the patient's asthma exacerbation objectively. By measuring the peak expiratory flow, the nurse can determine the degree of airflow limitation and response to treatment. This information guides appropriate interventions and helps in monitoring the effectiveness of the treatment. Notification of the healthcare provider (choice A) can be important but assessing the patient's respiratory status takes precedence. Teaching proper inhaler technique (choice B) and assessing adherence to maintenance medication (choice D) are important interventions but not the immediate priority when the patient is experiencing increased symptoms.
Question 5 of 5
A patient with tuberculosis is started on isoniazid. What should the nurse monitor for?
Correct Answer: B
Rationale: The correct answer is B: Peripheral neuropathy symptoms. Isoniazid can lead to peripheral neuropathy due to vitamin B6 deficiency. The nurse should monitor for numbness, tingling, or weakness in extremities. Signs of hepatotoxicity (choice A) are associated with other TB medications. Orange discoloration of body fluids (choice C) is a side effect of rifampin. Changes in visual acuity (choice D) are not typically associated with isoniazid.