NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 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?
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
Question 2 of 5
A client in hospice care is experiencing noisy, gurgling respirations. The nurse should:
Correct Answer: C
Rationale: Noisy, gurgling respirations (death rattle) are best managed by repositioning to a lateral position to allow secretions to drain, improving comfort without invasive measures.
Question 3 of 5
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the following would be a priority outcome for this client?
Correct Answer: C
Rationale: Severe flank pain is the most urgent issue, making pain alleviation the priority outcome to ensure client comfort and stability.
Question 4 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 5 of 5
The nurse is assessing a 42-year-old client with cancer. He has lost 1 lb in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 101°F (38.3°C). The fever is indicative of:
Correct Answer: D
Rationale: A fever of 101°F in a cancer patient, especially during chemotherapy, is most likely indicative of infection, which requires prompt evaluation due to immunosuppression.