ATI RN
Respiratory System NCLEX Questions Questions
Question 1 of 5
A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to assistive personnel (AP)?
Correct Answer: A
Rationale: The correct answer is A because applying water-soluble ointment to nares and lips helps prevent skin breakdown and discomfort caused by the oxygen flow. This task is within the scope of practice for assistive personnel (AP) as it does not require specialized medical knowledge or training. Choice B is incorrect because adjusting oxygen flow should only be done by licensed healthcare providers based on the client's prescribed oxygen therapy. Choice C is incorrect as replacing oxygen tubing requires knowledge of oxygen delivery systems and potential risks associated with incorrect tubing selection. Choice D is incorrect because turning the client every 2 hours is a nursing intervention related to preventing pressure ulcers, not specifically related to oxygen therapy comfort measures.
Question 2 of 5
Which of the following nursing activities is most important when a client comes back from a respiratory test if they have respiratory problems?
Correct Answer: B
Rationale: The correct answer is B. Assessing the airway is critical immediately after a respiratory test, especially if the client has pre-existing respiratory issues. A (rest) is secondary until stability is confirmed. C and D involve education, which is important but not urgent compared to ensuring airway patency.
Question 3 of 5
You are supervising a student nurse who is performing tracheostomy care for a client. For which action should you intervene?
Correct Answer: A
Rationale: The correct answer is A. Suctioning prior to tracheostomy care is incorrect because it increases the risk of introducing infection. Removing old dressings and cleaning secretions (B), removing and cleaning the inner cannula (C), and replacing the inner cannula and cleaning the stoma site (D) are standard steps in tracheostomy care.
Question 4 of 5
Following an asthmatic attack, a mother asks the physician how to prevent another asthmatic attack. The physician should:
Correct Answer: B
Rationale: The correct answer is B) Help the mother identify triggers that cause asthmatic attacks and show her how to avoid them. This is the most appropriate response because identifying and avoiding triggers is a key component of asthma management. By understanding what triggers an asthma attack, the mother can take proactive steps to minimize exposure to those triggers, thereby reducing the likelihood of future attacks. Option A is incorrect because it is not true that asthmatic attacks cannot be prevented. Asthma management focuses on prevention and control through various strategies, including trigger avoidance. Option C is incorrect because changing medication may be necessary in some cases, but it is not the first step in preventing asthma attacks. Identifying triggers and avoiding them should be the initial approach. Option D is incorrect because moving to a dry climate may not necessarily prevent asthma attacks, as triggers can vary and may not be solely related to climate. It is important to address specific triggers rather than making a drastic lifestyle change. In an educational context, it is crucial for healthcare providers to empower patients with the knowledge and tools to manage their conditions effectively. By educating the mother about asthma triggers and prevention strategies, the physician can help improve the quality of life for both the mother and her child with asthma.
Question 5 of 5
Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. What is the first action that the nurse should take?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Notify the health care provider. When a patient develops marked dyspnea and anxiety after pelvic surgery, it could indicate a pulmonary embolism, which is a life-threatening complication. The nurse should immediately notify the healthcare provider so that prompt intervention and treatment can be initiated to prevent further complications. Raising the head of the bed (Option A) may help improve breathing but is not the priority in this situation where a serious complication is suspected. Taking the patient's pulse and blood pressure (Option C) can provide some additional information, but it is not as urgent as notifying the healthcare provider. Determining the patient's SpO with an oximeter (Option D) can give information about oxygen saturation, but again, in this critical situation, immediate medical intervention is crucial. From an educational perspective, this question highlights the importance of recognizing and prioritizing urgent situations that require prompt action in a healthcare setting. Nurses need to be able to quickly assess and respond to changes in a patient's condition to ensure the best possible outcomes. Understanding the significance of symptoms like dyspnea and anxiety post-surgery can help nurses make timely decisions that can save lives.