NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 of 5
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.
Question 2 of 5
Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:
Correct Answer: B,D,G
Rationale: Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.
Question 3 of 5
The client diagnosed with lung cancer has been told the cancer has metastasized to the brain. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Brain metastasis impairs cognition, making driving unsafe (
C). Advance directives (
A), chemotherapy (
B), and proxy decisions (
D) are secondary or inappropriate.
Question 4 of 5
While developing the postoperative care plan for the client, it is essential to have the client lie in which position?
Correct Answer: A
Rationale: Positioning with the healthy lung uppermost optimizes ventilation and perfusion in the remaining lung post-pneumonectomy.
Question 5 of 5
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.