NCLEX Respiratory Questions

Extract:

Question 1 of 5

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

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.

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:

A. Apply cool compresses to affected extremity B. Measure leg circumference C. Massage affected extremity D. Elevate affected extremity above heart level E. Encourage frequent ambulation F. Monitor the patient's INR level G. Monitor the patient's aPTT level

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

Which health measure is most important to emphasize when instructing the client on ways to prevent transmitting tuberculosis?

A. Eat a nutritious diet. B. Get adequate sleep. C. Cover your nose and mouth when coughing. D. Wash your hands before and after meals.

Correct Answer: C

Rationale: Covering the nose and mouth when coughing prevents the spread of tuberculosis, an airborne disease, to others.

Question 4 of 5

Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?

A. Taking the client's temperature B. Assessing the client's blood pressure C. Monitoring the client's respiratory status D. Checking the client's pupillary response

Correct Answer: C

Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.

Question 5 of 5

Where did the client's embolism most likely originate?

A. The deep veins of the legs B. The pulmonary artery C. The superior vena cava D. The carotid artery

Correct Answer: A

Rationale: Pulmonary emboli most commonly originate from deep vein thrombosis in the legs, where clots dislodge and travel to the lungs.

NCLEX Respiratory Questions | Nurselytic

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