NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 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 2 of 5
Ventricular tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first?
Correct Answer: C
Rationale: Checking for a pulse determines if ventricular tachycardia is pulseless (requiring defibrillation) or stable (possibly requiring cardioversion or medication).
Question 3 of 5
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.
Question 4 of 5
A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
Question 5 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.