ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A patient with a tracheostomy tube exhibits difficulty breathing and thick secretions. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B - Perform tracheal suctioning. This action helps clear the thick secretions that are causing difficulty breathing. Tracheal suctioning is necessary for patients with tracheostomy tubes to maintain a clear airway. Encouraging deep breathing and coughing (choice A) may not be effective in clearing thick secretions from the trachea. Administering a bronchodilator (choice C) may help with bronchospasm but does not address the underlying issue of thick secretions. Repositioning the patient (choice D) may provide some relief but does not directly address the problem of airway obstruction due to thick secretions.
Question 5 of 5
The nurse observes continuous bubbling in the water-seal chamber of a chest tube. What does this indicate?
Correct Answer: B
Rationale: The continuous bubbling in the water-seal chamber indicates an air leak in the system. When air leaks into the chest tube system, it creates bubbling in the water-seal chamber. This indicates that the system is not airtight, compromising its ability to remove air or fluid from the pleural space effectively. Choices A, C, and D are incorrect because continuous bubbling does not indicate proper functioning of the chest tube, presence of a pneumothorax, or high suction pressure.