NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
Question 2 of 5
A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client complains of abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention?
Correct Answer: B
Rationale: Abdominal distention 2 days post-AAA repair is most likely due to paralytic ileus, a common postoperative complication from bowel manipulation and anesthesia, causing slowed gut motility. Bowel obstruction, peritonitis, or wound dehiscence would present with additional symptoms (e.g., fever, vomiting, or wound disruption).
Question 3 of 5
In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site?
Correct Answer: A
Rationale: Thrombocytopenia in leukemia increases bleeding risk in the gastrointestinal tract, brain/meninges, and pulmonary system due to mucosal surfaces and vascularity. The biliary system is not a common site for bleeding.
Question 4 of 5
The client has a nursing diagnosis of Self-care deficit related to the confinement of traction. Which of the following would indicate a successful outcome for this diagnosis?
Correct Answer: A
Rationale: Increased participation in self-care indicates progress toward independence despite traction limitations.
Question 5 of 5
A postoperative client is prescribed enoxaparin (Lovenox) 40 mg subcutaneous daily. Which laboratory value should the nurse monitor?
Correct Answer: A
Rationale: Enoxaparin can cause thrombocytopenia. Monitoring platelet count ensures early detection of this potential adverse effect.