NCLEX question
halago73
RESPIRATORY.pdf
1- Which medication prescriptions should the nurse question? Select all that
apply.
1.
Cephalexin for a client with severe allergy to penicillin
2.
Fexofenadine for a client with hives
3.
Ibuprofen for a client with asthma and nasal polyps
4.
Lisinopril for a client with diabetes mellitus
5.
Propranolol for a client with asthma
2- An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most?
1.
Alterations in color vision
2.
Gum (gingival) hypertrophy
3.
Hyperthermia
4.
Seizure activity
3- The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective?
1.
"I will always travel with two tracheostomy tubes, one of the same size and one a size
smaller."
2.
"I will immediately change the tracheostomy tube if my child has difficulty breathing."
3.
"I will provide deep suctioning frequently to prevent any airway obstruction."
4.
"I will remove the humidifier if my child starts developing more secretions."
4- A client is brought to the emergency department following a motor vehicle collision. The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min. The nurse anticipates the results of which diagnostic test to best evaluate the client's oxygenation and ventilation status?
1.
Arterial blood gases
2.
Chest x-ray
3.
Hematocrit and hemoglobin levels
4.
Serum lactate level
5- The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones?
1.
"If I am in the green zone (PEF 80%-100% of personal best) but am coughing, wheezing,
and having more trouble breathing, I will not make any changes in my medications."
2.
"If I am in the yellow zone (50%-80%) and I return to the green zone after taking my rescue
medication, I will not make any changes in my daily medications."
3.
"If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for
1-2 days and call my health care provider (HCP) for follow-up care."
4.
"If I remain in the red zone, my lips are blue, and my PEF is still <50% of my personal best
reading after taking my rescue medication, I will wait 15 minutes before calling an
ambulance."
6- A client is experiencing an asthma attack. The nurse assesses extreme anxiety, dyspnea, nonproductive cough, inspiratory and expiratory wheezing, and diminished breath sounds. Respirations are 36/min, pulse is 122/min, and pulse oximeter shows 87% on room air. Which is the priority nursing diagnosis (ND) for this client?
1.
Anxiety related to hypoxia and fear of suffocation
2.
Impaired gas exchange related to alveolar hypoventilation
3.
Ineffective airway clearance related to abnormal viscosity of mucus
4.
Ineffective breathing pattern related to decreased lung expansion
7- A 2-year-old child is brought to the emergency department for a severe sore throat and fever of 102.9 F (39.4 C). The nurse notes that the child is drooling with distressed respirations and inspiratory stridor. What action should the nurse take first?
1.
Assess an accurate temperature with a rectal thermometer
2.
Directly examine the throat for the presence of exudates
3.
Obtain intravenous access for anticipated steroid administration
4.
Position the child in tripod position on the parent's lap
8- A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply.
1.
Chest pain during inhalation
2.
Diminished breath sounds
3.
Dyspnea
4.
Hyperresonance on percussion
5.
Wheezing
9- A client with Alzheimer disease is found slumped over the lunch tray on the bedside
table, coughing violently with emesis visible in the back of the throat. The client has a
pulse of 135/min, respirations 32/min, and oxygen saturation 84%. The client also has
circumoral cyanosis and decreased level of consciousness. Place the nurse's actions
while awaiting the arrival of the rapid response team in priority order. All options
must be used.
Unordered Options
• Administer 100% oxygen by nonrebreather mask
• Assess lung sounds
• Notify the primary health care provider (HCP)
• Perform oropharyngeal suctioning
• Place client in high Fowler's position
10- The nurse receives change of shift report on 4 clients. Which client should the nurse assess first?
1.
6-month-old with respiratory syncytial virus and pulse oximetry of 90%
2.
1-year-old with otitis media and a temperature of 102.5 F (39.2 C) rectally
3.
2-year-old with suspected epiglottitis
4.
3-year-old who has a barking-type cough
•
11- The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease. Which client statement indicates appropriate understanding? Select all that apply.
1.
"I need to take iron to prevent anemia."
2.
"I should report an increase in sputum."
3.
"I will eat a low-calorie diet."
4.
"I will get a pneumococcal vaccine."
5.
"I will use albuterol if I am short of breath."
12- A nurse is caring for an elderly client who had a colectomy for removal of cancer
2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention?
1.
PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa)
2.
PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa)
3.
PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa)
4.
PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)
13- A 6-month-old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents?
1.
Monitor for and report development of a "white pupil"
2.
Perform manual chest physiotherapy
3.
Place child in knee-chest position during hypercyanotic episode
4.
Provide a low-calorie diet to prevent obesity
14- The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up?
1.
Client has 1 emesis of green fluid
2.
Client has had no bowel movement for 2 days
3.
Client falls asleep while talking to the nurse
4.
Client reports experiencing pruritus
15- The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom?
1.
Atropine sublingual drops
2.
Lorazepam sublingual tablet
3.
Morphine sublingual liquid
4.
Ondansetron sublingual tablet
16- The nurse performs the admission history for a 70-year-old client with newly diagnosed chronic obstructive pulmonary disease (COPD). Which statements made by the client does the nurse recognize as the most significant contributing factors to the development of COPD? Select all that apply.
1.
"I have been drinking alcohol almost daily since age 20."
2.
"I have been overweight for as long as I can remember."
3.
"I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year."
4.
"I know I eat too much fast food."
5.
"I was a car mechanic for about 40 years and had my own garage."
17- The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling?
1.
Air leak monitor
2.
Collection chamber
3.
Suction control chamber
4.
Water seal chamber
18- The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?
1.
Changing the inner cannula within the first 8 hours to help prevent mucus plugs
2.
Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these
ties
3.
Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage
4.
Performing frequent mouth care every 2 hours to help prevent infection
19- The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
1.
Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who
had a right pneumonectomy 12 hours ago
2.
Client with a left pleural effusion who has crackles, absent breath sounds in the left base,
and an SpO2 of 94% on room air
3.
Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small
bowel resection 1 day ago
4.
Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4
L/min supplemental oxygen, and is becoming restless
20- After the nurse receives the change-of-shift report, which client should the nurse assess first?
1.
Client with asthma who has shortness of breath and high-pitched expiratory wheezing
2.
Client with diabetes and a stasis leg ulcer dressing saturated with serosanguineous drainage
3.
Client with heart failure who is short of breath and coughing up pink frothy sputum
4.
Client with left pleural effusion and absent breath sounds in the left base
21- A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full face mask with continuous positive airway pressure (CPAP). Oxygen saturation drops to 85% during the night. What is the nurse's first action?
1.
Assess level of consciousness and lung sounds
2.
Check the tightness of the straps and mask
3.
Notify the health care provider immediately
4.
Remove the mask and administer supplemental oxygen
22- The client has a chest tube for a pneumothorax. While repositioning the client for an x-ray, the technician steps on the tubing and accidently pulls the chest tube out. The client's oxygen saturation drops and the pulse is 132/min; the nurse hears air leaking from the insertion site. What is the nurse's immediate action?
1.
Apply an occlusive sterile dressing secured on 3 sides
2.
Apply an occlusive sterile dressing secured on 4 sides
3.
Assess lung sounds
4.
Notify the health care provider (HCP)
23- The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)?
1.
Imbalanced nutrition
2.
Impaired gas exchange
3.
Impaired tissue integrity
4.
Risk for infection
24- Which is a management concern for a male teenage client with cystic fibrosis (CF)? Select all that apply.
1.
Diabetes insipidus
2.
Frequent respiratory infections
3.
Infertility
4.
Obesity
5.
Vitamin A deficiency
25- The nurse assesses a client with fever and productive cough for the last 10 days. Which findings support the presence of pneumonia? Select all that apply.
1.
Coarse crackles
2.
Hyperresonance
3.
Pleuritic chest pain
4.
Shortness of breath
5.
Trachea deviating from midline
26- The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a client who has a chest tube connected to wall suction for a pneumothorax. The client is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene?
1.
Clamping the chest tube at the insertion site during the transfer
2.
Disconnecting the suction tubing from the wall suction unit
3.
Hanging the chest tube collection unit to the underside of the stretcher
4.
Taping connections between the chest tube and suction tubing
27- The nurse is assisting the health care provider (HCP) with a client's chest tube removal. Just as the HCP prepares to pull the chest tube, what instructions should the nurse give the client?
1.
"Breathe as you normally would."
2.
"Inhale and exhale slowly."
3.
"Take a breath in, hold it, and bear down."
4.
"Take rapid shallow breaths, similar to panting."
28- The nurse is caring for a client admitted with incomplete fractures of right ribs 5- 7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time?
1.
Administer prescribed IV morphine
2.
Facilitate hourly client use of incentive spirometry
3.
Instruct client on gently splinting injury during coughing
4.
Notify the health care provider immediately
29- The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply.
1.
Bradycardia
2.
Chest pain
3.
Dyspnea
4.
Hypoxemia
5.
Tachypnea
6.
Tracheal deviation
30- A nurse is completing discharge teaching to the parent of a child who is
postoperative following a tonsillectomy. Which finding should be reported as a priority?
1.
Ear pain
2.
Frequent swallowing
3.
Low-grade fever
4.
Objectionable mouth odor
31- The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply.
1.
Add a thickening agent to the fluids
2.
Avoid sedating medications before meals
3.
Place head of bed at 30 degrees or more
4.
Restrict visitors who show signs of illness
5.
Teach neck flexion during swallowing
32- The nurse is assisting a client with asthma perform a peak flow meter
measurement. Place the instructions for measuring peak expiratory flow using a peak
flow meter in the correct order. All options must be used.
Unordered Options
• Exhale as quickly and completely as possible and note the reading on the scale
• Inhale deeply, place mouthpiece in mouth, and use the lips to create the seal
• Position the indicator on the flow meter scale to the lowest value and assume an
upright position
• Record the highest of the three measured values in the peak flow log
• Repeat the procedure 2 more times with a 5- to 10-second rest period between
exhalations
33- A client is transferred from the post-anesthesia recovery unit to the surgical unit
following an open cholecystectomy. Which interventions are most important for the
nurse to perform to prevent postoperative pneumonia? Select all that apply.
1.
Administer morphine only if the pain is >8 on a 1-10 pain scale
2.
Ambulate within 8 hours after surgery, if possible
3.
Have client cough with splinting every hour
4.
Have client deep breathe and use the incentive spirometer every hour
5.
Maintain pneumatic compression devices when client is in bed
6.
Place client in Fowler's position
34- Which pediatric respiratory presentation in the emergency department is a priority for nursing care?
1.
Client with an acute asthma exacerbation but no wheezing
2.
Client with bronchiolitis with low-grade fever and wheezing
3.
Client with runny nose with seal-like barking cough
4.
Cystic fibrosis client with fever and yellow sputum
35- Several children are brought to the emergency room after a boating accident in which they were thrown into the water. The children are now 6 hours post admission to the clinical observation unit. Which client should the nurse evaluate first?
1.
Client who did not require CPR but now has a new oxygen requirement of 2 L via nasal
cannula to maintain a saturation of 95%
2.
Client who did not require CPR but was coughing on arrival to the hospital and is now
crying inconsolably and asking for the mother
3.
Client who received CPR for 2 minutes on the scene and whose respiratory rate has now
dropped from 61/min to 18/min
4.
Client who was briefly submerged in water and received rescue breaths on the scene and is
now irritable and refusing food and drink
36- The registered nurse (RN) is caring for an elderly client with chronic obstructive pulmonary disease (COPD) whose pulse oximeter shows 91% on room air. After physical therapy, the client reports feeling "short of breath and exhausted" to the student nurse and says he just wants to sleep. To provide comfort, the student nurse initiates the prn nasal oxygen to maintain a saturation >92%, as prescribed. When the RN conducts end-of-shift rounds 3 hours later, the client is still sleeping soundly and the pulse oximeter shows 91%. Which nursing action is most appropriate at this time?
1.
Check a full set of vital signs
2.
Continue to monitor
3.
Increase the oxygen flow by 1 L/min
4.
Remove the nasal oxygen and measure saturation
