NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (
B) clears the airway, preventing further aspiration. Suctioning (
A), Trendelenburg (
C), and notification (
D) follow.
Question 3 of 5
You're providing discharge teaching to a patient who was admitted for pneumonia. You are discussing measures the patient can take to prevent pneumonia. Which of the following statements by the patient indicates they did NOT understand your education material?
Correct Answer: B
Rationale: The statement about not receiving the Pneumovax vaccine is incorrect, as vaccination is recommended to prevent pneumococcal pneumonia, and prior infection doesn't confer immunity. Other options reflect correct preventive measures.
Question 4 of 5
When suctioning the airway of a client with a tracheostomy, the nurse applies suction for no longer than how many seconds?
Correct Answer: B
Rationale: Suctioning for 10 to 12 seconds minimizes the risk of hypoxia and mucosal trauma.
Question 5 of 5
The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?
Correct Answer: 880
Rationale: Heparin rate: (20,000 units ÷ 500 mL) × 22 mL/hr = 40 units/mL × 22 mL/hr = 880 units/hr.