NCLEX-PN
NCLEX Questions Respiratory Questions
Extract:
Question 1 of 5
An adult is to have a thoracentesis performed. What should the nurse do while preparing the client for this procedure?
Correct Answer: C
Rationale: Explaining the procedure reduces anxiety and ensures the client understands what to expect during thoracentesis.
Question 2 of 5
A 52-year old female patient is receiving medical treatment for a possible tuberculosis infection. The patient is a U.S. resident but grew up in a foreign country. She reports that as a child she received the BCG vaccine (bacille Calmette-Guerin vaccine). Which physician's order below would require the nurse to ask the doctor for an order clarification?
Correct Answer: A
Rationale: The BCG vaccine can cause false-positive PPD (Mantoux) test results, making it unreliable in patients with a BCG history. The nurse should clarify this order, as an IGRA test (e.g., QuantiFERON-TB Gold) or other diagnostics are preferred.
Question 3 of 5
The nurse performs postural drainage on the client. Which nursing intervention is most beneficial to loosen secretions?
Correct Answer: B
Rationale: Striking the back with a cupped hand (percussion) helps loosen secretions during postural drainage.
Question 4 of 5
Which option below is considered a positive Homan's Sign for the assessment of a deep vein thrombosis (DVT)?
Correct Answer: A
Rationale: Homan's Sign is NOT reliable because of false positives, but know for exams how to elicit a response. It done by manually (forced) dorsiflexing the patient's foot (bending it up towards the shin) and if it causes the patient pain it considered a positive Homan's Sign. However, the MD must further investigate if the patient has a DVT.
Question 5 of 5
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the nurse?
Correct Answer: C
Rationale: Hypertension (198/102) with Procrit (
C) suggests a serious side effect, requiring immediate intervention. Hemoptysis (
A), tripod position (
B), and stomach upset (
D) are expected or less urgent.