NCLEX Respiratory Questions

Extract:

Question 1 of 5

The client has had a total laryngectomy. Which referral is specific for this surgery?

Correct Answer: C

Rationale: Lost Chord Club (
C) supports laryngectomy patients with communication and adjustment. CanSurmount (
A), Dialogue (
B), and SmokEnders (
D) are for cancer, CLL, and smoking cessation.

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 assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?

A. The client's urine output is 100 mL in four (4) hours. B. The pulse oximeter reading is greater than 95%. C. The client has asymmetrical chest expansion. D. The telemetry reading shows sinus tachycardia.

Correct Answer: C

Rationale: Asymmetrical chest expansion (
C) suggests pneumothorax, a ventilator complication. Low urine (
A), SpO2 >95% (
B), and tachycardia (
D) are unrelated or expected.

Question 4 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:

A. go get petrolatum gauze and apply over the wound. B. place her/his hand firmly over the wound. C. apply a sterile 4x4 dressing. D. reinsert the chest tube.

Correct Answer: B

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

Question 5 of 5

The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first?

A. Notify the health-care provider to have chest tubes reinserted STAT. B. Instruct the client to take slow shallow breaths until the tube is reinserted. C. Take no action and assess the client's respiratory status every 15 minutes. D. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

Correct Answer: D

Rationale: An occlusive dressing taped on three sides (
D) prevents air entry while allowing air exit, a priority. Notification (
A), shallow breaths (
B), and monitoring (
C) follow.

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