NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.
Question 2 of 5
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
Question 3 of 5
Which of the following indicates that the client with diabetes insipidus understands how to manage care?
Correct Answer: A
Rationale: Effective management of diabetes insipidus involves maintaining fluid and electrolyte balance through medication and adequate hydration.
Question 4 of 5
A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest?
Correct Answer: B
Rationale: A diet high in fiber (bran muffin, broccoli) and low in fat (skim milk) reduces colon cancer risk by promoting healthy digestion and reducing carcinogenic exposure in the colon.
Question 5 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.