Questions 108

NCLEX-RN

NCLEX-RN Test Bank

Adult Health II Respiratory NCLEX Questions Questions

Extract:


Question 1 of 5

A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?

Correct Answer: C,E

Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.

Question 2 of 5

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:

Correct Answer: C

Rationale: An alternating air pressure mattress (
C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (
A) and elevation (
D) are supportive but secondary. Abdominal massage (
B) is not indicated.

Question 3 of 5

A client undergoing chemotherapy tells the nurse, 'I do not want to get out of bed in the morning because I am so tired.' The nursing plan of care should include:

Correct Answer: B

Rationale: An individually tailored exercise program can help combat fatigue, improve energy levels, and enhance quality of life for chemotherapy patients.

Question 4 of 5

Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?

Correct Answer: A

Rationale: Septic shock is a major ARDS risk factor due to systemic inflammation and lung injury. COPD, asthma, and heart failure are not primary ARDS triggers.

Question 5 of 5

A client with acute renal failure has a potassium level of 6.5 mEq/L. The nurse should prepare for:

Correct Answer: A

Rationale: Insulin and glucose shift potassium into cells, treating hyperkalemia.

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