NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 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 2 of 5
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
Question 3 of 5
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
Question 4 of 5
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
Question 5 of 5
The nurse measures the amount of bile drainage from a T-tube and records it by which one of the following method:
Correct Answer: B
Rationale: T-tube drainage is bile output and should be recorded separately on the output record (option
B) to accurately track fluid loss. Adding it to urine output (
A) or wound drainage (
C) is incorrect as it represents a distinct type of output. Subtracting it from intake (
D) is not a standard practice.