NCLEX-PN
NCLEX Respiratory Questions Questions
Extract:
Question 1 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 2 of 5
Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?
Correct Answer: C
Rationale: Daily oral glucocorticoids (
C) are not typically used for asthma maintenance due to significant side effects; they are reserved for severe exacerbations or specific cases. Inhaled corticosteroids or leukotriene modifiers (like Singulair,
A) are preferred for long-term control. Using cromolyn before exercise (
B) is correct to prevent exercise-induced bronchospasm. Albuterol for acute attacks (
D) is appropriate as a rescue inhaler.
Question 3 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 4 of 5
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.
Question 5 of 5
When caring for a client with a flail chest, which nursing action is most appropriate?
Correct Answer: C
Rationale: Applying a chest binder stabilizes the flail chest, reducing paradoxical chest movement and improving ventilation.