ATI RN
Fundamentals of Nursing Oxygenation Questions Questions
Question 1 of 5
Which finding in a patient with asthma indicates a need for immediate intervention?
Correct Answer: A
Rationale: The correct answer is A: Use of accessory muscles during respiration. This finding in a patient with asthma indicates a need for immediate intervention because it signifies severe respiratory distress and impending respiratory failure. Accessory muscle use suggests that the patient is struggling to breathe and is unable to maintain adequate oxygenation. This requires prompt medical attention to prevent further deterioration. Summary: B: Oxygen saturation of 92% on room air may indicate mild hypoxemia but is not as urgent as the use of accessory muscles. C: Mild expiratory wheezing is a common finding in asthma exacerbations and may not necessarily require immediate intervention. D: Peak expiratory flow rate of 85% of personal best indicates moderate airflow limitation but does not necessarily require immediate intervention unless accompanied by other severe symptoms.
Question 2 of 5
The nurse observes diminished breath sounds on one side of a patient with a chest tube. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Check the chest tube for kinks or obstructions. The priority action is to ensure the chest tube is functioning properly as diminished breath sounds could indicate a blockage or dislodgement. By checking for kinks or obstructions first, the nurse can address the immediate issue and prevent complications. Reassessing after 30 minutes (A) delays necessary intervention. Clamping the tube (C) can lead to a tension pneumothorax. Notifying the healthcare provider (D) is important but not immediate in this situation.
Question 3 of 5
A patient with influenza develops crackles in the lungs. What should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Notify the provider of possible pneumonia. Crackles in the lungs in a patient with influenza could indicate pneumonia, which requires prompt treatment. Notifying the provider allows for further assessment and appropriate management. Monitoring vital signs (A) is important but does not address the potential complication of pneumonia. Providing supportive care and hydration (C) is necessary but does not address the urgent need to consider pneumonia. Administering decongestants (D) is not appropriate for treating pneumonia and may not address the underlying cause of crackles in the lungs.
Question 4 of 5
The nurse is caring for a patient with tuberculosis (TB). What instruction should the nurse prioritize?
Correct Answer: C
Rationale: The correct answer is C: Use a tissue to cover your mouth when coughing. This is the priority instruction because TB is spread through respiratory droplets. By covering the mouth when coughing, the patient reduces the risk of spreading the infection to others. Choice A is incorrect because wearing a mask outdoors does not prevent the spread of TB as effectively as covering the mouth when coughing. Choice B is incorrect because stopping medications prematurely can lead to treatment failure and drug resistance. Choice D is incorrect because there is no need to avoid dairy products while on TB treatment unless specifically advised by a healthcare provider.
Question 5 of 5
The nurse prepares a patient for a thoracentesis. What is the most appropriate action?
Correct Answer: C
Rationale: The most appropriate action is to instruct the patient to remain still during the thoracentesis procedure to minimize the risk of complications such as injury to surrounding tissues. Moving during the procedure can lead to inaccurate placement of the needle and potential damage. Positioning the patient in a semi-Fowler's position (A) is often used for comfort but not crucial for the procedure. Ensuring NPO status (B) is not necessary for thoracentesis. Administering analgesics (D) is not typically done before the procedure unless there is a specific reason.