ATI RN
NCLEX Style Questions on Oxygenation Questions
Question 1 of 5
Which finding in a patient with pneumonia should the nurse report immediately?
Correct Answer: A
Rationale: The correct answer is A because an oxygen saturation of 87% indicates severe hypoxemia, requiring immediate intervention to prevent complications like respiratory failure. Greenish sputum (B) suggests a possible bacterial infection but doesn't require immediate action. Fever (C) and a respiratory rate within normal range (D) are common findings in pneumonia and can be managed appropriately without immediate concern.
Question 2 of 5
The nurse assesses a patient with a thoracotomy. Which finding requires immediate intervention?
Correct Answer: B
Rationale: The correct answer is B because chest tube drainage of 200 mL in the first hour after thoracotomy indicates active bleeding or a significant air leak, requiring immediate intervention to prevent complications like tension pneumothorax or hemorrhage. A: Oxygen saturation of 91% is concerning but not immediately life-threatening. C: Subcutaneous emphysema is expected post-thoracotomy and may not require immediate intervention. D: Diminished breath sounds may indicate a complication but are not as urgent as significant chest tube drainage.
Question 3 of 5
The nurse assesses a patient with COPD who reports increased shortness of breath. What should the nurse do first?
Correct Answer: D
Rationale: Correct Answer: D. Check the patient's oxygen saturation. Rationale: 1. Check oxygen saturation first to assess patient's oxygen levels. 2. Low oxygen saturation can indicate respiratory distress in COPD. 3. This information guides subsequent interventions. 4. Other choices address symptom management but do not address the immediate need for oxygen assessment.
Question 4 of 5
Which assessment finding in a patient with pneumonia is most concerning?
Correct Answer: B
Rationale: The correct answer is B: Oxygen saturation of 86% on room air. This finding is most concerning in a patient with pneumonia because it indicates severe hypoxemia, which can lead to tissue damage and organ failure. Low oxygen saturation levels can be life-threatening and require immediate intervention. Rationale: 1. Oxygen saturation is a direct indicator of how well the lungs are oxygenating the blood. 2. A saturation level of 86% on room air is significantly below the normal range (typically 95-100%). 3. Hypoxemia can lead to tissue hypoxia, organ dysfunction, and even respiratory failure if left untreated. 4. Prompt oxygen therapy is necessary to improve oxygenation and prevent further complications. Summary: A: Respiratory rate of 24 breaths per minute - Elevated respiratory rate is common in pneumonia but not as concerning as severe hypoxemia. C: Fever of 100.4°F (38°C) - Fever is a common symptom of pneumonia but
Question 5 of 5
The nurse assesses a patient with pneumonia and notes confusion. What is the most likely cause?
Correct Answer: B
Rationale: The correct answer is B: Hypoxemia. Confusion in a patient with pneumonia is most likely due to lack of oxygen reaching the brain, which is caused by hypoxemia. When the lungs are infected, they are less able to oxygenate the blood, leading to hypoxemia. High fever (A) may cause delirium but is not the primary reason for confusion in pneumonia. Dehydration (C) can lead to confusion but is less likely in a patient with pneumonia. Sepsis (D) can cause confusion but is usually associated with other symptoms like low blood pressure and organ dysfunction.