ATI RN
NCLEX Questions on Oxygenation and Perfusion Questions
Question 1 of 5
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
Correct Answer: A
Rationale: The correct answer is A because a patient with a sore throat and a muffled voice may indicate a potential airway obstruction, such as peritonsillar abscess or epiglottitis, requiring immediate assessment to prevent respiratory compromise. Choice B is incorrect because a 'scratchy throat' and a positive rapid strep test may indicate a bacterial infection but do not pose an immediate threat to the airway. Choice C is incorrect as the patient receiving radiation for throat cancer and experiencing severe fatigue requires assessment but not as urgently as a potential airway obstruction. Choice D is incorrect because a red and inflamed stoma in a patient with a history of laryngectomy may indicate infection or irritation, but it does not pose an immediate threat to the airway as the patient already has a stoma for breathing.
Question 2 of 5
A patient with asthma develops wheezing and shortness of breath after using a dry powder inhaler. What is the nurse's priority action?
Correct Answer: A
Rationale: The correct answer is A: Administer a short-acting beta-agonist inhaler. This is the priority action because wheezing and shortness of breath indicate an exacerbation of asthma, which requires immediate bronchodilation to relieve symptoms. Administering a short-acting beta-agonist inhaler helps open the airways quickly, providing rapid relief. Assessing the peak flow reading (B) can provide valuable information but is not the priority when the patient is experiencing acute symptoms. Encouraging the patient to drink warm fluids (C) may provide comfort but does not address the urgent need for bronchodilation. Notifying the health care provider immediately (D) is important but should not delay the administration of bronchodilator therapy for acute asthma exacerbation.
Question 3 of 5
The nurse prepares to administer a bronchodilator to a patient experiencing an acute asthma exacerbation. Which medication should the nurse administer first?
Correct Answer: D
Rationale: The correct answer is D, Albuterol (Ventolin), because it is a short-acting bronchodilator that provides immediate relief by dilating the airways during an acute asthma exacerbation. This helps improve airflow and relieve symptoms quickly. Ipratropium (A) is another bronchodilator but is not as fast-acting as albuterol. Salmeterol (B) is a long-acting bronchodilator used for maintenance therapy, not for immediate relief during an acute attack. Montelukast (C) is a leukotriene receptor antagonist and is not a bronchodilator; it is used for long-term asthma control, not for acute exacerbations.
Question 4 of 5
The nurse is teaching a patient with asthma about the use of a rescue inhaler. Which statement indicates a need for further teaching?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Taking one puff and waiting 5 minutes before a second puff is incorrect as rescue inhalers are meant for immediate relief during asthma attacks. 2. Choice A is correct as using the inhaler before exercise can prevent exercise-induced symptoms. 3. Choice C is correct as cleaning the mouthpiece prevents clogging and ensures proper functioning. 4. Choice D is correct as using the inhaler when feeling short of breath is the appropriate time for immediate relief.
Question 5 of 5
The nurse observes that a patient with pneumonia has an oxygen saturation of 89%. What is the priority action?
Correct Answer: A
Rationale: Step 1: Oxygen saturation of 89% indicates hypoxemia, which can be life-threatening. Step 2: Administering oxygen therapy will help improve oxygenation levels. Step 3: Priority is to address hypoxemia to prevent complications. Step 4: Chest physiotherapy, deep breathing exercises, and sputum sample are not immediate priorities for hypoxemia. Administering oxygen is crucial to address the primary issue.