Chapter 41 Oxygenation Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationale

1. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which order should the nurse question? A. Oxygen at 2 L/min via nasal cannula B. Oxygen at 5 L/min via simple face mask C. Oxygen titrated to maintain SpO₂ above 90% D. Oxygen at 6 L/min via nasal cannula Correct Answer: D Rationale: Nasal cannulas should not exceed 6 L/min due to drying and limited effectiveness. In COPD, high oxygen levels can suppress respiratory drive, so the nurse should question oxygen at the upper limit of flow rate via nasal cannula. ________________________________________ 2. Which finding is most concerning in a patient with impaired oxygenation? A. Respiratory rate of 22 breaths/min B. Use of accessory muscles during respiration C. Oxygen saturation of 94% on room air D. Capillary refill less than 2 seconds Correct Answer: B Rationale: Use of accessory muscles indicates increased work of breathing and potential respiratory distress, which requires immediate nursing attention. ________________________________________ 3. The nurse auscultates diminished breath sounds in the lower lobes bilaterally. Which intervention is most appropriate? A. Administer a bronchodilator B. Encourage the patient to use the incentive spirometer C. Call the rapid response team D. Start high-flow oxygen therapy Correct Answer: B Rationale: Diminished breath sounds may indicate atelectasis or hypoventilation. Incentive spirometry encourages lung expansion and can help reopen alveoli. ________________________________________ 4. A patient is prescribed continuous pulse oximetry. Which condition might result in inaccurate readings? A. Hypothermia B. Fever C. Hyperglycemia D. Bradycardia Correct Answer: A Rationale: Hypothermia leads to peripheral vasoconstriction, which can interfere with pulse oximeter accuracy due to reduced peripheral blood flow. ________________________________________ 5. Which action by the nurse best promotes airway clearance in a postoperative patient? A. Encouraging the patient to eat solid foods B. Positioning the patient flat in bed C. Assisting the patient with coughing and deep breathing D. Administering opioids to reduce pain Correct Answer: C Rationale: Coughing and deep breathing help mobilize secretions and prevent complications like pneumonia and atelectasis in postoperative patients. ________________________________________ 6. A patient with pneumonia reports increased shortness of breath. What is the nurse’s priority action? A. Obtain a chest x-ray B. Increase the patient’s oral fluid intake C. Assess the patient’s oxygen saturation D. Notify the health care provider Correct Answer: C Rationale: Assessing oxygenation status is the priority to determine the severity of hypoxia and need for immediate interventions. ________________________________________ 7. Which lab value most directly reflects the patient’s oxygen-carrying capacity? A. Hemoglobin B. White blood cell count C. Hematocrit D. Platelet count Correct Answer: A Rationale: Hemoglobin carries oxygen in red blood cells. Low hemoglobin levels reduce oxygen delivery to tissues. ________________________________________ 8. A nurse is caring for a patient receiving oxygen at 2 L/min via nasal cannula. What should the nurse do to prevent mucosal drying? A. Decrease the oxygen flow rate B. Switch to a face mask C. Add humidification to the oxygen D. Suction the patient regularly Correct Answer: C Rationale: Humidification prevents drying of the mucosa, which is common with prolonged oxygen therapy via nasal cannula. ________________________________________ 9. Which nursing intervention is appropriate for a patient experiencing dyspnea? A. Encourage rapid shallow breathing B. Position the patient supine C. Elevate the head of the bed D. Restrict fluid intake Correct Answer: C Rationale: Elevating the head of the bed facilitates lung expansion and helps ease breathing in dyspneic patients.