NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
Question 2 of 5
When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following?
Correct Answer: C
Rationale: Effective deep breathing post-lobectomy involves relaxing abdominal muscles, taking a slow nasal breath, holding it 3–5 seconds, and exhaling to expand lungs. Contracting muscles or mouth breathing is less effective.
Question 3 of 5
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:
Correct Answer: B
Rationale: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.
Question 4 of 5
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.
Question 5 of 5
Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.