NCLEX Respiratory Questions

Extract:

Question 1 of 5

Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy?

Correct Answer: A

Rationale: Pain (alteration in comfort,
A) is a common issue post-thoracotomy due to surgical incision and chest tube placement, making it the most appropriate nursing diagnosis on day one. Altered consciousness (
B) is not typical unless complications arise. Elimination issues (
C) are less immediate. Knowledge deficit (
D) is relevant later for discharge teaching.

Question 2 of 5

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?

A. Notify the respiratory therapist immediately. B. Ventilate with a manual resuscitation bag. C. Request STAT arterial blood gases. D. Auscultate the client's lung sounds.

Correct Answer: B

Rationale: Manual ventilation (
B) ensures oxygenation during ventilator failure, a priority. Notification (
A), ABGs (
C), and auscultation (
D) follow.

Question 3 of 5

Your patient has a deep vein thrombosis in the left lower extremity. The patient is prescribed continuous IV Heparin. Select all the nursing interventions that are appropriate for this patient:

A. Apply cool compresses to affected extremity B. Measure leg circumference C. Massage affected extremity D. Elevate affected extremity above heart level E. Encourage frequent ambulation F. Monitor the patient's INR level G. Monitor the patient's aPTT level

Correct Answer: B,D,G

Rationale: Nursing interventions for this patient include: measuring leg circumference, elevating affected extremity above heart level, and monitoring aPTT level (for Heparin therapy). Why are the other options wrong? Option A: WARM compresses should be used, NOT cool (this will help with pain and circulation), Option C: this could dislodge the clot (NEVER massage or rub the site), Option E: the patient needs bed rest...ambulation could dislodge the clot, Option F: INR level is used to monitor Warfarin NOT Heparin, Option H: SCDs are NOT applied to an extremity with a clot because it could dislodge the clot...they are used to PREVENT blood clots.

Question 4 of 5

The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?

A. Daily inhaled corticosteroids. B. Use of a 'rescue inhaler.' C. Use of systemic steroids. D. Leukotriene agonists.

Correct Answer: B

Rationale: Mild intermittent asthma requires a rescue inhaler (
B) (e.g., albuterol) for PRN use. Daily corticosteroids (
A), systemic steroids (
C), and leukotrienes (
D) are for persistent asthma.

Question 5 of 5

The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first?

A. Notify the health-care provider to have chest tubes reinserted STAT. B. Instruct the client to take slow shallow breaths until the tube is reinserted. C. Take no action and assess the client's respiratory status every 15 minutes. D. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

Correct Answer: D

Rationale: An occlusive dressing taped on three sides (
D) prevents air entry while allowing air exit, a priority. Notification (
A), shallow breaths (
B), and monitoring (
C) follow.

NCLEX Respiratory Questions | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN