NCLEX Respiratory Questions

Extract:

Question 1 of 5

An adult has a chest drainage system. The client's wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:

Correct Answer: B

Rationale: Placing a hand firmly over the wound prevents air from entering the pleural space, which could cause a pneumothorax.

Question 2 of 5

Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition:

A. "The patient will not need treatment unless it progresses to an active tuberculosis infection." B. "The patient is not contagious and will have no signs and symptoms." C. "The patient will have a positive tuberculin skin test or IGRA test." D. "The patient will have an abnormal chest x-ray." E. "The patient's sputum will test positive for mycobacterium tuberculosis."

Correct Answer: B,C

Rationale: The patient WILL need medical treatment to prevent this case of LBTI from developing into an active TB infection later on. The patient will NOT have an abnormal chest x-ray or a positive sputum test. This is only in active TB.

Question 3 of 5

The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first?

A. Milk the chest tube. B. Check the tubing for kinks. C. Instruct the client to cough. D. Assess the insertion site.

Correct Answer: B

Rationale: No tidaling in the water-seal compartment suggests a blockage or kink. Checking for kinks (
B) is the first, non-invasive action to restore function. Milking (
A) is avoided due to pressure risks. Coughing (
C) is ineffective if tubing is blocked. Assessing the site (
D) is secondary.

Question 4 of 5

Which of the following best indicates that the client's grief is beginning to resolve?

A. The client wants only the spouse to visit. B. The client says the physician made an incorrect diagnosis. C. The client looks at the tracheostomy tube in a mirror. D. The client asks the nurse for help with bathing.

Correct Answer: C

Rationale: Looking at the tracheostomy tube in a mirror suggests acceptance of the body image change, indicating progress in resolving grief.

Question 5 of 5

The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?

A. Administer the ordered oral antibiotic immediately (STAT). B. Order the meal tray to be delivered as soon as possible. C. Obtain a sputum specimen for culture and sensitivity. D. Have the unlicensed assistive personnel weigh the client.

Correct Answer: C

Rationale: Obtaining sputum culture (
C) before antibiotics ensures accurate pathogen identification, a priority. Antibiotics (
A) follow, meals (
B) and weight (
D) are less urgent.

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