ATI RN
Oxygen Therapy NCLEX Questions Questions
Question 1 of 5
Which finding in a patient with respiratory distress requires the nurse's immediate intervention?
Correct Answer: A
Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, noisy breathing sound typically heard on inspiration, indicating upper airway obstruction. This finding requires immediate intervention as it can lead to airway compromise and respiratory distress. Explanation for why other choices are incorrect: B: Cough productive of yellow sputum may indicate a respiratory infection but does not necessarily require immediate intervention. C: Oxygen saturation of 92% on 2 L/min oxygen is concerning but not immediately life-threatening. It may require adjustment of oxygen therapy. D: Respiratory rate of 20 breaths per minute falls within the normal range and does not indicate immediate intervention is needed.
Question 2 of 5
A nurse is caring for a patient who is undergoing chemotherapy. Which intervention should be implemented to prevent infection?
Correct Answer: B
Rationale: The correct answer is B: Administer prophylactic antibiotics. This intervention helps prevent infection in the patient undergoing chemotherapy by targeting potential pathogens before they cause harm. Chemotherapy can weaken the immune system, making patients more susceptible to infections. Providing a mask (choice A) may help reduce exposure but does not directly address preventing infection. Repositioning the patient (choice C) is important for preventing complications like pressure ulcers but does not specifically target infection prevention. Performing a sputum culture (choice D) is useful for diagnosing respiratory infections but does not focus on preventing infections proactively. Administering prophylactic antibiotics is a targeted approach to reducing the risk of infection in immunocompromised patients.
Question 3 of 5
A patient with a history of diabetes is experiencing dizziness and confusion. What should the nurse do first?
Correct Answer: D
Rationale: The correct answer is D: Administer an antiemetic. When a patient with diabetes presents with dizziness and confusion, it could indicate hypoglycemia. However, administering glucose without confirming the blood sugar level can be dangerous if the patient's symptoms are not due to low blood sugar. Administering an antiemetic first can help rule out other causes of the symptoms, such as nausea or vomiting, before addressing potential hypoglycemia. Administering glucagon injection or oral glucose should only be done if confirmed hypoglycemia.
Question 4 of 5
A 55-yr-old patient with increasing dyspnea is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD). When teaching a patient about pulmonary spirometry for this condition, what is the most important question the nurse should ask?
Correct Answer: C
Rationale: The correct answer is C: Have you had frequent streptococcal throat infections? This is the most important question to ask because repeated streptococcal throat infections can lead to bronchiectasis, which is a risk factor for COPD. Bronchiectasis causes permanent dilation of the bronchi, leading to airflow obstruction. It is crucial to assess this history as it can provide valuable information on the patient's risk for developing COPD. A: Are you claustrophobic? - This question is not directly related to the assessment for COPD through pulmonary spirometry. B: Have you taken any bronchodilators today? - While important for assessing current medication use, it is not as crucial as determining the history of streptococcal throat infections. D: Do you use antihistamines for upper airway congestion? - Antihistamine use may not be directly linked to the risk factors for COPD development.
Question 5 of 5
A nurse is caring for a patient with a history of diabetes who is experiencing hypoglycemia. What should the nurse do first?
Correct Answer: A
Rationale: The correct answer is A: Administer glucose. The first step in managing hypoglycemia is to increase the patient's blood sugar level. Administering glucose helps to rapidly raise the blood sugar levels, which is crucial in treating hypoglycemia in a patient with diabetes. Administering insulin therapy (choice B) or insulin (choice C) would further lower the blood sugar levels, worsening the hypoglycemic state. Administering oxygen (choice D) is not indicated for hypoglycemia and would not address the underlying issue of low blood sugar levels. Administering glucose is the priority to quickly correct the hypoglycemia and prevent potential complications.