NCLEX-RN
NCLEX RN Medical Surgical Questions and Answers Questions
Extract:
Question 1 of 5
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
Question 2 of 5
Which symptom suggests worsening neurological status in a client with a head injury?
Correct Answer: B
Rationale: Decreased pulse rate (bradycardia) may indicate increased intracranial pressure, a sign of worsening neurological status.
Question 3 of 5
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (
A), slow nasal inhalation with pursed-lip exhalation (
B), holding the breath (
C), and repeating 5-10 times hourly (
D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
Question 4 of 5
Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
Correct Answer: D
Rationale: Splinting the rib cage during coughing stabilizes the chest, reducing pleuritic pain. Shallow breathing may worsen atelectasis. Abdominal breathing aids ventilation but not pain. 'Inceptive spirit' is likely a typo for incentive spirometry, which promotes lung expansion but not direct pain relief.
Question 5 of 5
The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action?
Correct Answer: B
Rationale: PVCs every other beat (bigeminy) may indicate serious irritability. Assessing orientation and vital signs first determines the client's stability, guiding further actions.