NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 of 5
When caring for a client with influenza, the nurse would expect to assess for which signs and symptoms of hypoxia? Select all that apply.
Correct Answer: B, D, E, F
Rationale: Hypoxia manifests as restlessness, tachypnea, use of accessory muscles, and cyanosis due to inadequate oxygen delivery to tissues.
Question 2 of 5
An adult has a chest drainage system. The client's wife reports to the nurse that her husband is restless. The nurse enters the room just in time to see him pull out his chest tube. The most appropriate initial action for the nurse to take is to:
Correct Answer: B
Rationale: Placing a hand firmly over the wound prevents air from entering the pleural space, which could cause a pneumothorax.
Question 3 of 5
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: Manual ventilation (
B) ensures oxygenation during ventilator failure, a priority. Notification (
A), ABGs (
C), and auscultation (
D) follow.
Question 4 of 5
Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?
Correct Answer: C
Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.
Question 5 of 5
Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:
Correct Answer: B,C,D
Rationale: Virchow's Triad details the THREE factors for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Patients who experience sepsis are at risk for hypercoagulability of the blood. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Patients who've had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc.