ATI RN
Oxygenation NCLEX Questions Questions
Question 1 of 5
Which nursing intervention is most effective for a patient with thick respiratory secretions?
Correct Answer: A
Rationale: The correct answer is A: Encourage the patient to drink at least 2 liters of water daily. This intervention promotes hydration, which helps to liquefy thick respiratory secretions, making them easier to expectorate. Drinking adequate water also maintains mucous membrane hydration. Option B (mucolytics) may be prescribed but may not be as effective without sufficient hydration. Option C (suctioning) is invasive and should be done cautiously to prevent mucosal damage. Option D (chest physiotherapy) helps with secretion mobilization but may not be as directly effective as hydration in liquefying secretions. In summary, promoting hydration is the most effective and least invasive intervention for a patient with thick respiratory secretions.
Question 2 of 5
The nurse assesses a patient with chest trauma and notes paradoxical chest movement. What is the nurse's priority action?
Correct Answer: C
Rationale: Rationale: 1. Paradoxical chest movement indicates a serious condition like flail chest, causing impaired breathing. 2. Oxygen therapy is the priority to ensure adequate oxygenation and prevent respiratory distress. 3. Administering pain medication may mask symptoms and delay appropriate intervention. 4. Chest tube insertion may be needed but is not the immediate priority. 5. Positioning the patient on the affected side is not recommended as it can worsen respiratory distress. Summary: Oxygen therapy is crucial to address respiratory compromise in chest trauma with paradoxical chest movement, while other options may not directly address the underlying issue or could potentially delay appropriate care.
Question 3 of 5
How should a nurse position a patient for a thoracentesis with a left-sided pleural effusion?
Correct Answer: B
Rationale: The correct answer is B, sitting upright with arms supported on an over-bed table. This position allows for better visualization of the thoracentesis site, facilitates proper needle insertion, and minimizes the risk of complications such as pneumothorax. High-Fowler's position with the left arm extended (choice A) may not provide adequate access to the pleural effusion. Supine with the head of the bed elevated 30 degrees (choice C) may not allow for proper drainage and visualization. Lying on the right side with the left arm elevated (choice D) is incorrect as it does not facilitate proper access to the pleural effusion site.
Question 4 of 5
A patient recovering from a thoracotomy has no chest tube drainage for 2 hours. What should the nurse do first?
Correct Answer: B
Rationale: The correct answer is B: Assess the chest tube for kinks or obstructions. This is the first step because if there are any kinks or obstructions in the chest tube, it could lead to inadequate drainage and potentially cause complications such as pneumothorax or hemothorax. Repositioning the patient (choice A) may be necessary after ensuring the chest tube is functioning properly. Notifying the healthcare provider (choice C) should be done after assessing the chest tube. Increasing suction pressure (choice D) without assessing for kinks or obstructions may worsen the situation.
Question 5 of 5
A patient reports severe chest pain and difficulty breathing after a thoracentesis. What is the nurse's priority action?
Correct Answer: C
Rationale: The correct answer is C because reassessing vital signs and oxygen saturation is crucial to determine the patient's current status and the severity of the symptoms. This step allows the nurse to quickly identify any potential complications or deterioration in the patient's condition. Administering analgesic (choice A) may temporarily alleviate pain but does not address the underlying issue. Notifying the healthcare provider (choice B) is important but should not delay immediate assessment and intervention. Positioning the patient on the affected side (choice D) is not appropriate in this scenario and may worsen the symptoms.