NCLEX-RN
Adult Health II Respiratory NCLEX Questions Questions
Extract:
Question 1 of 5
Which of the following nursing interventions is most important in preventing postoperative complications?
Correct Answer: D
Rationale: Early ambulation prevents multiple complications, including deep vein thrombosis, pneumonia, and atelectasis, by promoting circulation and lung expansion.
Question 2 of 5
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
Correct Answer: C
Rationale: An alternating air pressure mattress (
C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (
A) and elevation (
D) are supportive but secondary. Abdominal massage (
B) is not indicated.
Question 3 of 5
A client with renal calculi has hematuria. The nurse should:
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
Question 4 of 5
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
Question 5 of 5
The client is ready for discharge after surgery for a deviated septum. Which of the following discharge instructions would be appropriate?
Correct Answer: A
Rationale: Avoiding Valsalva's maneuver (e.g., straining, heavy lifting) prevents increased pressure that could cause bleeding or disrupt the surgical site.