Practice Question
The nurse is admitting a client diagnosed with acute respiratory failure secondary to emphysema. The primary health care provider prescription includes: Arterial Blood Gas (ABG)'s, chest X-ray, continuous pulse oximetry, aminophylline infusion at 35 mg/hr, methylprednisolone 125 mg intravenous push (IVP) every 6 hours. Which intervention would the nurse implement FIRST?
Answer Choices:
Correct Answer:
Attach the pulse oximeter.
Rationale:
🟢 Pulse oximetry provides rapid, noninvasive assessment of oxygen saturation.
🟢 Determines the degree of hypoxia, guiding urgency of interventions.
🟢 Quick initial step before escalating care (e.g., oxygen or ABGs).
🟢 Confusion and cyanosis are signs of impaired cerebral and peripheral oxygenation.
🟢 Establishing a baseline SpO₂ is critical to monitor therapy effectiveness.
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This question is from Custom: NUR 202 Test 1B Spring~2025 which contains 61 questions.
More Questions from This Exam
The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who has developed atelectasis. Which collaborative intervention would the nurse anticipate the health care provider to prescribe to best assist in opening the client's collapsed alveoli?
Answer Choices:
A. Increased respiratory rate.
B. Positive End Expiratory Pressure (PEEP)
C. Supine positioning.
D. Increased tidal volume
A client is receiving an intravenous push (IVP) medication. If this type of medication infiltrates into the outer tissues of the forearm during the IVP, what is the FIRST response of the nurse?
Answer Choices:
A. Complete a safety event report
B. Follow facility policy or the drug literature (drug manufacturer) directions.
C. Apply a warm compress to the infiltrated site.
D. Continue to administer the IV push medication slower than the required administration rate
A client is prescribed lorazepam. What does the nurse know to be TRUE regarding this medication?
Answer Choices:
A. Abrupt discontinuation of high doses may cause severe withdrawal symptoms.
B. It has a maximum adult dose of 25 mg/day
C. It interferes with the binding of dopamine receptors.
D. When combined with benztropine the risk for extrapyramidal symptoms is increased.
A client diagnosed with Post-Traumatic Stress Disorder (PTSD) is in their room experiencing a flashback. The client is re-living auditory and visual elements of the traumatic event. Which nursing intervention is MOST appropriate?
Answer Choices:
A. Reduce external stimuli by leaving the client alone in their room.
B. Discuss prior coping strategies with the client.
C. Use simple words and instructions to communicate with the client.
D. Provide reassurance by holding the client's hand.
A client is on a mechanical ventilator via an oral endotracheal tube (ETT). Both the ventilator and oxygen saturation monitor are alarming. The nurse notes that the oxygen saturation has dropped from 94% to 78%. The nurse auscultates breath sounds in the left lung only. Which conclusion would the nurse make
Answer Choices:
A. The mechanical ventilator is malfunctioning.
B. The endotracheal tube is occluded due to a mucus plug
C. The patient may have developed a pneumothorax.
D. The size of the endotracheal tube is inappropriate.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Adult Health
- Answer Choices: 4