NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 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 2 of 5
Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:
Correct Answer: D
Rationale: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.
Question 3 of 5
The nurse has reported to the hospital to work the evening shift on a respiratory unit. The nurse's assignment consists of four clients. Prioritize in order from highest to lowest priority how the nurse would assess the clients after receiving report.
Order the Items
Source Container
Correct Answer: A,B,C,D
Rationale: The client with pneumonia, fever, and shortness of breath is at highest risk for respiratory compromise (
A). The postoperative client with pain (
B) is next due to pain's impact on breathing. The client with suspected tuberculosis and cough (
C) is lower priority but needs isolation precautions. The client with emphysema awaiting a scheduled bronchodilator (
D) is stable.
Question 4 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 5 of 5
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
Correct Answer: A,C,D
Rationale: No weight gain (
A), medication adherence (
C), and low hospitalization rates (
D) indicate effective management of heart failure through monitoring and teaching.