ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
Which finding in a patient with pneumonia requires immediate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B because an oxygen saturation of 88% indicates severe hypoxemia, requiring immediate intervention to prevent tissue damage. Oxygen therapy is crucial to improve oxygenation. Choice A is not as urgent as hypoxemia. Choice C indicates fluid in the lungs but does not require immediate action. Choice D is within the normal range for respiratory rate.
Question 2 of 5
A patient receiving mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). What is the best intervention?
Correct Answer: B
Rationale: The correct answer is B: Perform oral care with chlorhexidine. This intervention helps reduce the risk of VAP by decreasing oral bacteria that can potentially be aspirated into the lungs. Proper oral care is essential in preventing VAP. Administering prophylactic antibiotics (A) may lead to antibiotic resistance. Keeping the patient sedated at all times (C) can increase the risk of aspiration. Increasing the frequency of suctioning (D) can irritate the airway and potentially introduce more bacteria.
Question 3 of 5
The nurse assesses a patient with a chest tube and notes subcutaneous emphysema. What is the appropriate action?
Correct Answer: B
Rationale: The correct answer is B: Document the finding and continue monitoring. Subcutaneous emphysema in a patient with a chest tube indicates air leakage but does not require immediate intervention. Clamping the chest tube could lead to tension pneumothorax. Notifying the healthcare provider is important but not urgent unless other symptoms are present. Replacing the chest tube drainage system is not necessary at this point. Regular monitoring and documentation allow for appropriate intervention if the condition worsens.
Question 4 of 5
A patient with pneumonia is experiencing confusion and restlessness. What is the nurse's priority intervention?
Correct Answer: B
Rationale: The correct answer is B because confusion and restlessness in a pneumonia patient may indicate hypoxia. Oxygen saturation should be reassessed as hypoxia can be life-threatening. Providing supplemental oxygen helps improve oxygenation. Administering an antipyretic (A) may help reduce fever but addressing hypoxia is more critical. Increasing fluid intake (C) and positioning the patient (D) are important but addressing hypoxia takes precedence in this scenario.
Question 5 of 5
Which finding in a patient post-lobectomy requires immediate action?
Correct Answer: B
Rationale: The correct answer is B because an oxygen saturation of 89% indicates severe hypoxemia, which can be life-threatening and requires immediate intervention to prevent tissue damage or organ failure. Oxygen is essential for cellular metabolism, and a saturation below 90% can lead to serious complications. A: Drainage of 150 mL in the first hour is within the expected range post-lobectomy and does not require immediate action. C: Mild incisional pain is a common finding post-surgery and can be managed with appropriate pain medication; it does not necessitate immediate action. D: Absent air leak in the chest tube is a desired outcome post-lobectomy, indicating proper lung re-expansion and no immediate intervention is needed in this case.