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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

Which assessment finding provides the best evidence that a client with a long history of smoking is experiencing respiratory difficulty?

Correct Answer: A

Rationale: A pulse oximeter reading of 85% indicates low oxygen saturation, a direct sign of respiratory difficulty in a smoker.

Question 2 of 5

The physician orders enoxaparin (Lovenox) for a client who has been diagnosed with a blood clot. To prevent bruising, which actions by the nurse are most appropriate? Select all that apply.

Correct Answer: A,F

Rationale: Avoiding rubbing and applying gentle pressure minimize bruising at the injection site for enoxaparin.

Question 3 of 5

Which instruction regarding rescue breathing is important to include in the parent-teaching plan when a newborn is at risk for sudden infant death syndrome (SIDS)?

Correct Answer: B

Rationale: For infant rescue breathing, covering the nose and mouth and blowing just enough air to make the chest rise ensures effective ventilation without overinflation.

Question 4 of 5

The nurse observes a nursing assistant assigned to a client who just returned from having a bronchoscopy. Which action by the nursing assistant would prompt the nurse to intervene?

Correct Answer: B

Rationale: After a bronchoscopy, the client is at risk for airway compromise due to anesthesia or swelling. Offering water before the gag reflex returns can lead to aspiration, requiring intervention.

Question 5 of 5

Which assessment findings provide the nurse with the best indications that a client's tracheostomy needs suctioning? Select all that apply.

Correct Answer: C,E,F

Rationale: Noisy respirations, coughing up sputum, and a low pulse oximeter reading (87%) indicate airway obstruction or secretions that require suctioning. A slowed pulse rate, cool/moist skin, and elevated respiratory rate are not specific indicators for suctioning.

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