ATI RN
Oxygenation NCLEX Questions with Rationale Questions
Question 1 of 5
Which nursing action is most effective in preventing ventilator-associated pneumonia (VAP)?
Correct Answer: A
Rationale: The correct answer is A: Performing oral care with chlorhexidine. This action is effective in preventing VAP by reducing the bacterial load in the oral cavity, which can decrease the risk of aspiration of pathogens into the lungs. Chlorhexidine has antimicrobial properties that help to kill or inhibit the growth of bacteria. Regular oral care can help maintain oral hygiene and prevent colonization of pathogens. Choice B, administering antibiotics prophylactically, is not recommended as routine prophylactic use of antibiotics can lead to antibiotic resistance and disrupt the normal flora, potentially causing more harm than good. Choice C, suctioning the airway every hour, is important for maintaining airway patency but is not the most effective action for preventing VAP. Over-suctioning can irritate the airway and increase the risk of infection. Choice D, keeping the patient sedated at all times, is not a recommended practice as it can lead to complications such as ventilator-associated pneumonia. Sedation can impair the
Question 2 of 5
A patient with pneumonia has an oxygen saturation of 88%. What is the nurse's priority intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen therapy immediately. With an oxygen saturation of 88%, the patient is experiencing hypoxemia, which can lead to tissue damage and organ dysfunction. Administering oxygen therapy is crucial to improve oxygen levels and prevent further complications. Other choices are incorrect because: B: Encouraging deep breathing and coughing may be beneficial, but addressing hypoxemia is the priority. C: Obtaining a sputum culture is important but not immediate in this situation. D: Positioning the patient in high Fowler's position can help with breathing, but addressing the low oxygen saturation is the priority.
Question 3 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 4 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 5 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.