NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse measures the amount of bile drainage from a T-tube and records it by which one of the following method:
Correct Answer: B
Rationale: T-tube drainage is bile output and should be recorded separately on the output record (option
B) to accurately track fluid loss. Adding it to urine output (
A) or wound drainage (
C) is incorrect as it represents a distinct type of output. Subtracting it from intake (
D) is not a standard practice.
Question 2 of 5
Which of the following interventions would be least appropriate for a client who is in a double hip spica cast?
Correct Answer: D
Rationale: Dangling at the bedside is inappropriate, as it risks cast damage and improper positioning.
Question 3 of 5
The risk for injury during an attack of Ménière'sdisease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
Correct Answer: D
Rationale: Assuming a reclining or flat position during a vertigo attack minimizes the risk of falling and injury by stabilizing the client's position.
Question 4 of 5
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
Correct Answer: A,C,D
Rationale: No weight gain (
A), medication adherence (
C), and low hospitalization rates (
D) indicate effective management of heart failure through monitoring and teaching.
Question 5 of 5
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
Order the Items
Source Container
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (
C) due to potential infection indicated by a moist dressing, followed by culturing drainage (
B) to identify the organism, changing the dressing (
A) to maintain sterility, and positioning a towel (
D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize