NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 of 5
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.
Question 2 of 5
Which clinical manifestation would the nurse assess in the client newly diagnosed with intrinsic lung cancer?
Correct Answer: C
Rationale: Hoarseness (
C) is a common early symptom of intrinsic lung cancer due to tumor compression of the recurrent laryngeal nerve. Dysphagia (
A) is more typical of esophageal involvement. Foul-smelling breath (
B) is non-specific. Weight loss (
D) occurs later in advanced disease.
Question 3 of 5
The physician orders the patient to start taking Omalizumab. How will you administer this medication as the nurse?
Correct Answer: D
Rationale: Omalizumab is administered subcutaneously for asthma treatment.
Question 4 of 5
The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
Correct Answer: 880
Rationale: Heparin rate: (20,000 units ÷ 500 mL) × 22 mL/hr = 40 units/mL × 22 mL/hr = 880 units/hr.
Question 5 of 5
The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?
Correct Answer: B
Rationale: Placing a towel over the mirror (choice 2) suggests the client is avoiding looking at their altered appearance due to the radical neck dissection, indicating a disturbance in body image. This surgery often results in visible changes, such as scarring or a tracheostomy, which can impact self-perception. Requesting a speech therapist (choice 1) focuses on communication, attempting to shave (choice 3) shows engagement in self-care, and practicing exercises (choice 4) indicates recovery efforts, none of which directly reflect body image issues.