NCLEX Exam medical surgery

NCLEX Exam medical surgery

NCLEX Exam: Respiratory System Disorders (60 Questions)

Question 1 Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it

may cause:

A Nasal congestion B Nervousness C Lethargy D Hyperkalemia Question 2 Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the

drainage. In acute rhinitis, nasal drainage normally is:

A Yellow B Green C Clear D Gray

Question 3 A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

A Nausea or vomiting B Abdominal pain or diarrhea C Hallucinations or tinnitus D Lightheadedness or paresthesia Question 4 Before administering ephedrine, Nurse Tony assesses the patient’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for: A Patients with an acute asthma attack B Patients with narcolepsy C Patients under age 6 D Elderly patients

Question 5 A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient’s condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?A Kinking of the ventilator tubing B A disconnected ventilator tube

C An endotracheal cuff leak D A change in the oxygen concentration without resetting the oxygen level alarm Question 6 A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?A Leg movement B Finger movement C Lip movement D Fighting the ventilator

Question 7 On auscultation, which finding suggests a right pneumothorax?A Bilateral inspiratory and expiratory crackles B Absence of breaths sound in the right thorax C Inspiratory wheezes in the right thorax D Bilateral pleural friction rub Question 8 Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase “a” in ABG value present?A Acid-base balance B Arterial Blood C Arterial oxygen saturation D Alveoli

Question 9 A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?A Activity intolerance related to fatigue B Anxiety related to actual threat to health status C Risk for infection related to retained secretions D Impaired gas exchange related to airflow obstruction Question 10 Nurse Ruth assessing a patient for tracheal displacement should know that the

trachea will deviate toward the:

A Contralateral side in a simple pneumothorax B Affected side in a hemothorax C Affected side in a tension pneumothorax D Contralateral side in hemothorax

Question 11 After undergoing a left pneumonectomy, a female patient has a chest tube in place

for drainage. When caring for this patient, the nurse must:

A Monitor fluctuations in the water-seal chamber B Clamp the chest tube once every shift C Encourage coughing and deep breathing D Milk the chest tube every 2 hours Question 12 When caring for a male patient who has just had a total laryngectomy, the nurse

should plan to:

A Encourage oral feeding as soon as possible B Develop an alternative communication method C Keep the tracheostomy cuff fully inflated D Keep the patient flat in bed

Question 13 A male patient has a sucking stab wound to the chest. Which action should the nurse take first?A Drawing blood for a hematocrit and hemoglobin level B Applying a dressing over the wound and taping it on three sides C Preparing a chest tube insertion tray D Preparing to start an I.V. line Question 14 For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?A Encouraging the patient to drink three glasses of fluid daily B Keeping the patient in semi-fowler’s position C Using a high-flow venturi mask to deliver oxygen as prescribe D Administering a sedative, as prescribe

Question 15 A male patient’s X-ray result reveals bilateral white-outs, indicating adult

respiratory distress syndrome (ARDS). This syndrome results from:

A Cardiogenic pulmonary edema B Respiratory alkalosis C Increased pulmonary capillary permeability D Renal failure Question 16 For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?A Restricting fluid intake to 1,000 ml per day B Enforcing absolute bed rest C Teaching the patient how to perform controlled coughing D Administering prescribe sedatives regularly and in large amounts

Question 17 Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate?A Do nothing, because this is an expected finding B Immediately clamp the chest tube and notify the physician

C Check for an air leak because the bubbling should be intermittent D Increase the suction pressure so that the bubbling becomes vigorous Question 18 Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?A Inform the physician B Continue to monitor the client C Reinforce the occlusive dressing D Encourage the client to deep-breathe

Question 19 Nurse Reynolds caring for a client with a chest tube turns the client to the side, and

the chest tube accidentally disconnects. The initial nursing action is to:

A Call the physician B Place the tube in bottle of sterile water C Immediately replace the chest tube system D Place a sterile dressing over the disconnection site Question 20 A nurse is assisting a physician with the removal of a chest tube. The nurse should

instruct the client to:

A Exhale slowly B Stay very still C Inhale and exhale quickly D Perform the Valsalva maneuver

Question 21 While changing the tapes on a tracheostomy tube, the male client coughs and tube

is dislodged. The initial nursing action is to:

A Call the physician to reinsert the tube B Grasp the retention sutures to spread the opening C Call the respiratory therapy department to reinsert the tracheotomy D Cover the tracheostomy site with a sterile dressing to prevent infection Question 22 Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?A Stridor B Occasional pink-tinged sputum C A few basilar lung crackles on the right D Respiratory rate 24 breaths/min

Question 23