ATI RN
Fundamentals of Nursing Oxygenation Practice Questions Questions
Question 1 of 5
Which clinical management prevention concept would the nurse identify as representative of secondary prevention?
Correct Answer: D
Rationale: In this scenario, the correct answer is option D) Prevention of pneumonia in patients with chronic lung disease, which exemplifies secondary prevention in clinical management. Secondary prevention involves interventions aimed at preventing and treating existing health problems to avoid further complications. In the context of oxygenation, patients with chronic lung disease are already at risk for respiratory infections like pneumonia due to compromised lung function. By implementing strategies to prevent pneumonia in this high-risk group, the nurse is engaging in secondary prevention by addressing an existing health issue to prevent exacerbation or complications. Option A) Decreasing venous stasis and risk for pulmonary emboli pertains more to primary prevention as it focuses on reducing the initial occurrence of a health problem, in this case, preventing the development of pulmonary emboli by addressing venous stasis. Option B) Implementation of strict hand washing routines is a measure of infection control and falls under the category of primary prevention by reducing the risk of acquiring infections in the first place. Option C) Maintaining current vaccination schedules is also a form of primary prevention as it aims to prevent the initial development of vaccine-preventable diseases through immunization. In an educational context, understanding the different levels of prevention (primary, secondary, and tertiary) is crucial for nurses to effectively plan and implement interventions to promote patient health and prevent complications. By recognizing the distinction between these levels, nurses can tailor their care to address specific patient needs at different stages of the disease process, ultimately improving patient outcomes and enhancing the quality of care provided.
Question 2 of 5
An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?
Correct Answer: D
Rationale: In triaging clients with chest discomfort, selecting the client who describes intense squeezing pressure across the chest (Option D) as the first to assess is crucial due to the classic presentation of acute myocardial infarction (AMI). This symptom is indicative of a potentially life-threatening condition that requires immediate intervention to prevent further cardiac damage or complications. Option A describes pain as a dull ache, which is less likely to be associated with an acute cardiac event and may indicate a less urgent issue. Option B, moderate pain worse on inspiration, could suggest musculoskeletal or respiratory origin rather than a cardiac issue. Option C, cramping substernal pain, while concerning, may not carry the same urgency as the intense squeezing pressure associated with AMI. Educationally, understanding the distinct characteristics of chest pain associated with different conditions is vital for nurses to prioritize care effectively in emergency situations. By recognizing the significance of specific symptoms like intense squeezing pressure in the context of AMI, nurses can expedite appropriate assessments and interventions, potentially saving lives and improving patient outcomes.
Question 3 of 5
The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client?
Correct Answer: D
Rationale: In the context of a client with an alteration in respiratory function, the most significant laboratory finding would be a blood pH of 7.32 (option D). This finding indicates acidosis, which is crucial in respiratory dysfunction as it reflects an imbalance in acid-base status, likely due to CO2 retention from inadequate ventilation. Option A, Hemoglobin level of 14 g/dL, is generally within the normal range and does not directly indicate respiratory impairment. Option B, Oxygen saturation of 96%, reflects adequate oxygenation but does not provide information about respiratory function. Option C, Serum sodium of 140 mg/dL, is also within the normal range and is not directly related to respiratory dysfunction. Understanding laboratory values in the context of respiratory dysfunction is crucial for nurses to provide effective care. Abnormal blood pH levels can indicate potential respiratory failure, prompting timely interventions. This knowledge helps nurses interpret results accurately, tailor interventions to the client's needs, and collaborate with the healthcare team to optimize respiratory function and overall patient outcomes.
Question 4 of 5
The nurse is providing care to a client admitted after experiencing an acute asthma attack. Which assessment findings should the nurse identify as signs that the client has progressed to respiratory failure? Select all that apply.
Correct Answer: C
Rationale: In the context of caring for a client who has experienced an acute asthma attack, the assessment finding of inaudible breath sounds (Option C) is indicative of progression to respiratory failure. Inaudible breath sounds suggest severe airway obstruction, which can lead to inadequate gas exchange and respiratory compromise. This finding requires prompt intervention to prevent further deterioration. Option A (Retractions and fatigue) and Option B (Tachycardia and tachypnea) are common manifestations of respiratory distress in asthma but do not specifically indicate progression to respiratory failure. Retractions and increased respiratory rate and heart rate are often seen in asthma exacerbations before respiratory failure occurs. These signs underscore the severity of the condition but may not necessarily indicate imminent respiratory failure. Option D (Diffuse wheezing and the use of accessory muscles when inhaling) are typical findings in an acute asthma attack but do not specifically signal progression to respiratory failure. Wheezing and the use of accessory muscles reflect airway constriction and increased work of breathing, which are characteristic of asthma exacerbations. However, the absence of wheezing and the inability to hear breath sounds altogether (Option C) are more concerning as they indicate a severe obstruction compromising airflow. Educationally, understanding these nuances in assessment findings is crucial for nurses caring for clients with respiratory conditions like asthma. Recognizing subtle changes in respiratory status and knowing which signs indicate imminent respiratory failure empowers nurses to intervene promptly and effectively, potentially preventing further deterioration and improving patient outcomes.
Question 5 of 5
The nurse is providing care to a client recently diagnosed with chronic obstructive pulmonary disease (COPD). Which conditions will you include when you teach the client's family about the types of COPD?
Correct Answer: C
Rationale: In educating the client's family about the types of COPD, it is crucial to provide accurate information to ensure proper understanding and care. The correct answer, option C (Bronchitis and emphysema), is the right choice because these two conditions are the primary types of COPD. Bronchitis involves inflammation of the airways, leading to increased mucus production and airway narrowing. Emphysema, on the other hand, is characterized by damage to the alveoli, the tiny air sacs in the lungs responsible for gas exchange. Option A (Asthma and bronchitis) is incorrect because while asthma is a chronic respiratory condition, it is not considered a type of COPD. Option B (Asthma and emphysema) is also incorrect because, as mentioned earlier, asthma is a separate respiratory condition from COPD. Option D (Emphysema and atelectasis) is incorrect as well because atelectasis refers to the collapse of a lung or a portion of it, which is not a type of COPD. When teaching about COPD, it is essential to highlight the differences between asthma and COPD, as well as to emphasize the impact of bronchitis and emphysema on the lungs. Providing this knowledge can help the family better understand the client's condition, adhere to treatment plans, and support their loved one in managing COPD effectively. It is important to stress the importance of lifestyle modifications, medication adherence, and regular follow-ups with healthcare providers to optimize COPD management and improve the client's quality of life.