NCLEX Respiratory Questions and Rationales

NCLEX Respiratory Questions and Rationales Leave the first rating Students also studied Terms in this set (20) Science MedicineEmergency Medicine Save Respiratory NCLEX Questions 131 terms rwillia2Preview Ch. 40 Fluid, Electrolyte, and Acid-B...15 terms hcps-rockechrr Preview Respiratory Questions with answers ...52 terms HLH13Preview July 18t 37 terms Wh the medical surgical nurse cares for a client who had a mediastinal tumor removed 2 days ago and reports difficulty breathing. the client becomes confused and restless, and respirations re 30/min. what is the nurses next action.A.) administer a dose of prescribed prn anti-anxiety medication B.) call the health care provider who preformed the surgery C.) call the rapid response team D.) place the client in the left lateral recovery position C.) call the rapid response team Rationale: when a client is demonstrating clinical deterioration, the nurses priority is to prevent full respiratory or cardiac arrest by calling the rapid response team the nurse is teaching a 9 year old child with asthma how to use a metered dose inhaler. place the instructions in the correct order 1.) shake the MDI and attach it to a spacer 2.) Exhale completely 3.) place lips tightly around the mouth piece 4.) deliver one puff of medication into spacer 5.) take a slow deep breath and hold for 10 seconds 6.) rinse mouth with water

a self employed auto mechanic is diagnosed with carbon monoxide poisoning. admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. what is the nurses priority action A.) administer 5 mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction B.) administer 100% oxygen using a non-rebreather mask with a flow of 15 L/min C.) administer methylprednisone to decrease lung inflammation from toxic inhalant D.) titrate oxygen to maintain pulse oximeter saturation of greater than 95% B.) administer 100% oxygen using a non-rebreather mask with a flow of 15 L/min Rationale: the conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning. diagnosis requires co-oximetry of a blood gas sample. the priority action is to administer 100% oxygen using a nonrebreather mask t treat hypoxia and help eliminate CO the hospice nurse is caring for an actively dying a client who is unresponsive and developed a loud rattling sound when breathing ("death rattle") that distresses family members. which prescription would be most appropriate to treat this symptom A.) atropine sublingual drops B.) lorazepam sublingual tablet C.) morphine sublingual liquid D.) ondansetron sublingual tablet A.) atropine sublingual drops Rationale: the "death rattle" is a noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and no longer able to manage airway secretions. anticholinergic medications such as transdermal scopolamine or atropine sublingual drops effectively treat this symptom by drying up excess secretions a 2 year old child is brought to the emergency department for a severe sore throat and fever of 102.9 F.the nurse notes that the child is drooling with distressed respirations and inspiratory stridor. which action should the nurse take first A.) assess an accurate temperature with a rectal thermometer B.) directly examine the throat for the presence of exudates C.) obtain an intravenous access for anticipated steroid administration D.) position the child in a tripod position on their parents lap D.) position the child in a tripod position on their parents lap

Rationale: children with potential epiglottitis should be allowed a position of

comfort without nay invasive or anxiety-provoking procedures until the airway is secure with intubation or a surgical airway

the nurse receives the handoff of care report on 4 clients. which client should the nurse see first A.) 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 B.) client with a left pleural effusion who has crackles, absent breath sounds in the left base, and a SPO2 of 94% on room air C.) client with temperature of 100.4 F and a respiratory rate of 12/min who had a small bowel resection 1 day ago D.) client with pneumonia who has temperature of 97.6 F has an SPO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless D.) client with pneumonia who has temperature of 97.6 F has an SPO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless Rationale: Acute respiratory failure is a life threatening impairment of lung function that inhibits gas exchange. common s/s include altered mental status (confusion, agitation, somnolence), parathesisas, dyspnea, tachypnea, all of which should be addressed immediately which medications prescriptions should the nurse question. select all that apply A.) cephalexin for a client with severe allergy to penicillin B.) fexofenadine for a client with hives C.) ibuprofen for a client with asthma and nasal polyps D.) lisinopril for a client with diabetes mellitus E.) propanolol for a client with asthma A.) cephalexin for a client with severe allergy to penicillin C.) ibuprofen for a client with asthma and nasal polyps E.) propanolol for a client with asthma Rationale: clients with asthma have a sensitivity to NSAIDS; those with an allergy to penicillin can have a cross sensitivity to cephalosporins. non-selected betablockers are contraindicated in clients with asthma 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 A.) i will always travel with two tracheostomy tubes, one of the same size and one a size smaller B.) i will immediately change the tracheostomy tube if my child has difficulty breathing C.) i will provide deep suctioning frequently to prevent any airway obstruction D.) i will remove the humidifier if my child starts developing more secretions A.) i will always travel with two tracheostomy tubes, one of the same size and one a size smaller

Rationale: clients with a tracheostomy should always carry two spare tubes, one

the same size and one a size smaller, to ensure that the tube can be replaced quickly and effectively the nurse is teaching an overweight 54 year old client about ways to decrease symptoms of obstructive sleep apnea. which interventions would be most effective.select all that apply A.) eating a high protein snack at bedtime B.) limiting alcohol intake C.) losing weight D.) taking a mild sedative at bedtime E.) taking modanfinil at bedtime F.) taking a nap during the day B.) limiting alcohol intake C.) losing weight Rationale: obstructive sleep apnea is characterized by partial or complete airway obstruction during sleep. interventions to relieve symptoms include a continuous positive airway pressure device during sleep and lifestyle changes (weight loss, exercise, avoiding food, alcohol, sedatives at bedtime)

the client with malignant left pleural effusion undergoes a thorancentesis and 900 mL of excess pleural fluid is removed. which of these medications, if noted on the post procedure assessment, should the nurse report to the health provider immediately A.) asymmetrical chest expansion and decreased breath sounds on the left B.) blood pressure 100/65 mm Hg C.) client complains of 6/10 pain at the needle insertion site D.) respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min A.) asymmetrical chest expansion and decreased breath sounds on the left

Rationale: complications of thoracentesis include iatrogenic pneumothorax,

hemothroax, and infection. post-procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds a nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. which intervention should the nurse implement first A.) administer prescribed analgesic medication for incisional pain B.) encourage use of incentive spirometer every 2 hours while awake C.) offer additional pillow to splint the incision while coughing D.)promote increased oral fluid intake A.) administer prescribed analgesic medication for incisional pain Rationale: the nurse should ensure that the postoperative client has effective pain relief before performing coughing exercises the nurse is caring for a client with advanced heart failure on an inpatient hospice unit. the client is having trouble breathing. which comfort intervention should the nurse implement first A.) administer as need prn albuterol by nebulizer B.) administer prn intravenous (iv) furosemide C.) elevate the head of bed D.) give prn sublingual morphine C.) elevate the head of bed Rationale: the first intervention should be to elevate the head of the bed and then assess for fluid overload, which would then be treated with IV diuretics the nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. which of the following is the nurses priority when caring for a client with a new tracheostomy A.) changing the inner cannula within the first 8 hours to help prevent mucous plugs B.) checking the tightness of ties and adjusting if necessary, allowing one finger to fit under the ties C.) deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage D.) performing frequent mouth care every 2 hours to help prevent infection B.) checking the tightness of ties and adjusting if necessary, allowing one finger to fit under the ties

Rationale: the immediate postoperative goal for a client with a newly placed

tracheostomy is to prevent accidental dislodgment of the tube and loss of airway