NCLEX-PN
NCLEX Questions Respiratory Questions
Extract:
Question 1 of 5
A 72 year-old male patient who is diagnosed with bilateral lower lobe pneumonia is admitted to your unit. The patient has a history of systolic heart failure and arthritis. On assessment, you note the patient has a respiratory rate of 21 , oxygen saturation $93 \%$ on $2 \mathrm{~L}$ nasal cannula, is alert & oriented, and has a productive cough with green/yellowish sputum. Which of the following nursing interventions will you provide to this patient based on your assessment findings and the patient's diagnosis? Select-all-that-apply:
Correct Answer: B,D
Rationale: Sputum cultures identify the causative organism, and incentive spirometer use promotes lung expansion. Head-of-bed <30 degrees increases aspiration risk, 3L fluids may overload heart failure patients, and Pneumovax is not annual.
Question 2 of 5
You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis:
Correct Answer: C,D,E,F
Rationale: Remember from our lecture we discussed the risk factors for developing TB and to remember them I said remember the mnemonic "TB Risk". It stands for tight living quarters (LTC resident, prison, homeless shelter etc.), below or at the poverty line (homeless), refugee (especially in high risk countries), immune system issue such as HIV, substance abusers (IV drugs or alcohol), Kids less than the age of 5....all these are risk factors.
Question 3 of 5
An adult has a chest drainage system. Several hours after the chest tube was inserted, the nurse observes that there is no bubbling in the water seal chamber. What is the most likely reason for the absence of bubbling?
Correct Answer: A
Rationale: No bubbling in the water seal chamber typically indicates lung reexpansion, as air is no longer leaking from the lung into the pleural space.
Question 4 of 5
The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention is the nurse's priority?
Correct Answer: D
Rationale: Literacy (
D) ensures post-laryngectomy communication (e.g., writing), a priority. ICU visit (
A), pain requests (
B), and TED hose (
C) are secondary.
Question 5 of 5
Which nursing action is most appropriate immediately after the chest tube is removed from the client?
Correct Answer: A
Rationale: Applying a sterile dressing taped securely prevents air entry into the pleural space and promotes healing post-chest tube removal.