A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?

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NCLEX RN Questions on Respiratory System Questions

Question 1 of 5

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?

Correct Answer: A

Rationale: The correct action is to document the findings first because the harsh hollow sound over the trachea and larynx could indicate a potential issue with the airway or respiratory function. Documenting the findings allows for accurate communication with other healthcare providers and helps track changes in the client's condition. Administering oxygen therapy or albuterol should not be done without further assessment or orders from a healthcare provider. Positioning the client in high-Fowler position may not be the priority until a more thorough assessment is completed.

Question 2 of 5

A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?

Correct Answer: C

Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly. Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.

Question 3 of 5

Which of the following should the nurse include in the teaching plan of a client with acute bronchitis?

Correct Answer: C

Rationale: The correct answer is C. Frequent handwashing prevents the spread of infection, which is crucial in managing acute bronchitis. A (not coughing frequently) is impractical and counterproductive. B (consuming adequate calories) supports general health but is not specific. D (semi-Fowler’s position) may aid breathing but is not a primary teaching point.

Question 4 of 5

Client history and assessment reveals all of these findings. Which finding supports the diagnosis of PE?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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