The client is getting out of bed and becomes very

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Question 1 of 5

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first?

A. Administer oxygen 10 L via nasal cannula. B. Place the client in high Fowler's position. C. Obtain a STAT pulse oximeter reading. D. Auscultate the client's lung sounds.

Correct Answer: B

Rationale: High Fowler’s position (
B) improves breathing in suspected PE, a priority. Oxygen (
A), SpO2 (
C), and lung sounds (
D) follow to support and assess.

Question 2 of 5

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse?

A. The UAP keeps the chest tube below chest level. B. The UAP has the chest tube attached to suction. C. The UAP allowed the client out of the bed. D. The UAP uses a bedside commode for the client.

Correct Answer: B

Rationale: Suction during ambulation (
B) restricts mobility and risks dislodgement, requiring intervention. Below chest level (
A), ambulation (
C), and commode (
D) are appropriate.

Question 3 of 5

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax?

A. Gentle bubbling in the suction compartment. B. No fluctuation (tidaling) in the water-seal compartment. C. The drainage compartment has 250 mL of blood. D. The client is able to deep breathe without any pain.

Correct Answer: B

Rationale: No tidaling (
B) indicates lung re-expansion, showing effective hemothorax treatment. Bubbling (
A) suggests air leak, drainage (
C) is expected, and pain-free breathing (
D) is secondary.

Question 4 of 5

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment?

A. Assess the client's bilateral lung sounds. B. Obtain an order for a STAT chest x-ray. C. Notify the health-care provider as soon as possible. D. Document the findings in the client's chart.

Correct Answer: A

Rationale: No tidaling may indicate resolution or obstruction; assessing lung sounds (
A) confirms status. CXR (
B), notification (
C), and documentation (
D) follow.

Question 5 of 5

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, 'What is happening to me? Why did I get this?' Which statement by the nurse is most appropriate?

A. Most people who almost drown end up developing ARDS. B. Platelets and fluid enter the alveoli due to permeability instability. C. Your lungs are filling up with fluid, causing breathing problems. D. Smoking has caused your lungs to become weakened, so you got ARDS.

Correct Answer: C

Rationale: Fluid-filled lungs (
C) explain ARDS simply, addressing breathing issues. Drowning link (
A), permeability (
B), and smoking (
D) are less accurate or overly technical.

Nurselytic

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NCLEX Questions Respiratory Questions

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