NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 of 5
While developing the postoperative care plan for the client, it is essential to have the client lie in which position?
Correct Answer: A
Rationale: Positioning with the healthy lung uppermost optimizes ventilation and perfusion in the remaining lung post-pneumonectomy.
Question 2 of 5
How long after administering a tuberculin skin test should the nurse inspect the client's injection site?
Correct Answer: C
Rationale: The tuberculin skin test reaction is typically read 48 to 72 hours (2 to 3 days) after administration to assess for induration.
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:
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 unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?
Correct Answer: B
Rationale: Lowering the bed (
B) prevents falls, critical for ARDS patients. Demonstration (
A), extra help (
C), and praise (
D) are inappropriate given safety concerns.
Question 5 of 5
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (
B) clears the airway, preventing further aspiration. Suctioning (
A), Trendelenburg (
C), and notification (
D) follow.