NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is teaching a client with a total knee replacement about incision care. Which statement by the client indicates a need for further teaching?
Correct Answer: C
Rationale: Changing the dressing weekly is too infrequent; daily or as-needed changes are required to monitor for infection.
Question 2 of 5
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client's arrival?
Correct Answer: C,E
Rationale: Respirations and blood pressure are the priority assessments for a C7 spinal cord injury, as this level can impair diaphragmatic function and cause neurogenic shock, both life-threatening. Reflexes, bladder function, and temperature are important but secondary to airway and circulation stability.
Question 3 of 5
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do?
Correct Answer: B
Rationale: Coffee should be removed because caffeine can alter brain wave activity, affecting EEG results. The other foods do not typically interfere with the test.
Question 4 of 5
The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors?
Correct Answer: B
Rationale: In Parkinson's disease, resting tremors often decrease or disappear during purposeful movements, such as unbuttoning a shirt. This is a characteristic feature, not psychological, distraction-related, or random.
Question 5 of 5
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.