NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 of 5
The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client?
Correct Answer: A
Rationale: Pneumonia causes pleuritic chest pain and anxiety (
A) from inflammation/hypoxia. Asymmetry (
B) suggests pneumothorax, leukopenia (
C) is atypical, and substernal pain (
D) suggests MI.
Question 2 of 5
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
Correct Answer: D
Rationale: Hemoptysis (
D) suggests serious conditions (e.g., lung cancer, T
B), requiring investigation. VapoRub (
A), appendectomy (
B), and vitamins (
C) are benign.
Question 3 of 5
A patient is admitted with rupture of the Achilles tendon. The patient was recently treated with antibiotics for pneumonia. Which of the following medications below can cause this adverse effect?
Correct Answer: B
Rationale: Fluoroquinolones are associated with tendon rupture, including Achilles tendon, as a rare but serious side effect. Other antibiotics listed (A, C,
D) are not commonly linked to this adverse effect.
Question 4 of 5
The client is admitted to emergency department complaining of shortness of breath and fever. The vital signs are T 100.4°F, P 94, R 26, and BP 134/86. Which concept should the nurse identify as a concern for the client? Select all that apply.
Correct Answer: B,C
Rationale: SOB and tachypnea (
B) suggest oxygenation issues, and fever (
C) indicates infection. Clotting (
A), perfusion (
D), and coping (E) are not primary based on data.
Question 5 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:
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.