(2026) NURSING !!! NCLEX EXAM GRADES A + WITH
RELEVANT SOLUTIONS TO QUESTIONS 4
1. Question1 point(s)
A nurse is caring for a client with diabetic ketoacidosis and documents that the
client is experiencing Kussmaul’s respirations. Based on this documentation,
which of the following did the nurse most likely observe? Select all that apply.
A. Respirations that cease for several seconds
B. Respirations that are regular but abnormally slow
Incorrect
C. Respirations that are labored and increased in-depth and rate
D. Respirations that are abnormally deep, regular, and increased in rate
Correct Answer
E. Respirations are rapid and shallow but as acidosis worsens, breathing gradually
becomes deep, labored, and gasping
Correct Answer
Incorrect
Correct Answer: D & E.
,Kussmaul’s respiration is a deep and labored breathing pattern often associated
with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also
kidney failure. It is a form of hyperventilation. It results from stimulation of the
respiratory center in the brain stem by low serum pH.
Option A: In apnea, respirations cease for several seconds. Apnea is the absence
of breathing. This signals a life-threatening situation in which the patient will
quickly succumb unless rescue breathing is instituted immediately.
Option B: In bradypnea, respirations are regular but abnormally slow. Bradypnea
is a respiratory rate that is lower than normal for age.
Option C: In hyperpnea, respirations are labored and increased in depth and rate.
Hyperpnea in increased volume with or without an increased rate of breathing.
Blood gasses are normal.
Option D: They are abnormally deep, regular, and increased in rate. As classically
described, Kussmaul respirations are a deep, sighing respiratory pattern. Dr.
Kussmaul actually described it as “air hunger.” Kussmaul’s respiratory pattern
occurs due to increased tidal volume with or without an increased respiratory
rate.
Option E: In metabolic acidosis, breathing is first rapid and shallow but as acidosis
worsens, breathing gradually becomes deep, labored, and gasping. This is
probably the most important of the abnormal respiratory patterns.
2. Question1 point(s)
,Which nursing interventions are appropriate for a client recovering from surgery
for retinal detachment? Select all that apply.
A. Monitor for hemorrhage.
Correct Answer
B. Administer eye medications.
Correct Answer
C. Maintain the eye patch or shield.
Correct Answer
D. Assist with activities of daily living.
Correct Answer
E. Encourage coughing and deep breathing.
Incorrect
F. Educate regarding symptoms of retinal detachment.
Correct Answer
Incorrect
Correct Answer: A, B, C, D, & F.
, Retinal detachments constitute a serious ocular condition and can lead to
permanent vision loss. When the retina, the neurosensory layer, detaches from
the back of the eye, it loses its oxygen and nutrient supply leading to the death of
the tissue.
Option A: Hemorrhage is also a risk post-surgery. Spontaneous choroidal
hemorrhage often occurs either intraoperatively or in the immediate
postoperative period.
Option B: Eye medications are prescribed postoperatively. Zylet drops minimize
inflammation and the risk of infection following retina surgery. Alphagan drop is
used to control eye pressure. Atropine minimizes pain caused by swelling and
inflammation, following retina surgery.
Option C: An eye patch or shield is applied to protect the eye and prevent any
further detachment. Protective shields should be worn for at least a week and
guidelines should be followed closely to ensure incisions heal properly without
disruption.
Option D: Positioning, activity restrictions, and eye patches hinder the client in
the performance of activities of daily living, and the client needs the nurse’s
assistance with these activities. Activity must be restricted, and patients should
refrain from bending and heavy lifting (2-10 lb. limit).
Option E: Coughing is not encouraged because this can increase intraocular
pressure and harm the client. Coughing has been implicated in the development
of spontaneous choroidal hemorrhage in the immediate postoperative period.
RELEVANT SOLUTIONS TO QUESTIONS 4
1. Question1 point(s)
A nurse is caring for a client with diabetic ketoacidosis and documents that the
client is experiencing Kussmaul’s respirations. Based on this documentation,
which of the following did the nurse most likely observe? Select all that apply.
A. Respirations that cease for several seconds
B. Respirations that are regular but abnormally slow
Incorrect
C. Respirations that are labored and increased in-depth and rate
D. Respirations that are abnormally deep, regular, and increased in rate
Correct Answer
E. Respirations are rapid and shallow but as acidosis worsens, breathing gradually
becomes deep, labored, and gasping
Correct Answer
Incorrect
Correct Answer: D & E.
,Kussmaul’s respiration is a deep and labored breathing pattern often associated
with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also
kidney failure. It is a form of hyperventilation. It results from stimulation of the
respiratory center in the brain stem by low serum pH.
Option A: In apnea, respirations cease for several seconds. Apnea is the absence
of breathing. This signals a life-threatening situation in which the patient will
quickly succumb unless rescue breathing is instituted immediately.
Option B: In bradypnea, respirations are regular but abnormally slow. Bradypnea
is a respiratory rate that is lower than normal for age.
Option C: In hyperpnea, respirations are labored and increased in depth and rate.
Hyperpnea in increased volume with or without an increased rate of breathing.
Blood gasses are normal.
Option D: They are abnormally deep, regular, and increased in rate. As classically
described, Kussmaul respirations are a deep, sighing respiratory pattern. Dr.
Kussmaul actually described it as “air hunger.” Kussmaul’s respiratory pattern
occurs due to increased tidal volume with or without an increased respiratory
rate.
Option E: In metabolic acidosis, breathing is first rapid and shallow but as acidosis
worsens, breathing gradually becomes deep, labored, and gasping. This is
probably the most important of the abnormal respiratory patterns.
2. Question1 point(s)
,Which nursing interventions are appropriate for a client recovering from surgery
for retinal detachment? Select all that apply.
A. Monitor for hemorrhage.
Correct Answer
B. Administer eye medications.
Correct Answer
C. Maintain the eye patch or shield.
Correct Answer
D. Assist with activities of daily living.
Correct Answer
E. Encourage coughing and deep breathing.
Incorrect
F. Educate regarding symptoms of retinal detachment.
Correct Answer
Incorrect
Correct Answer: A, B, C, D, & F.
, Retinal detachments constitute a serious ocular condition and can lead to
permanent vision loss. When the retina, the neurosensory layer, detaches from
the back of the eye, it loses its oxygen and nutrient supply leading to the death of
the tissue.
Option A: Hemorrhage is also a risk post-surgery. Spontaneous choroidal
hemorrhage often occurs either intraoperatively or in the immediate
postoperative period.
Option B: Eye medications are prescribed postoperatively. Zylet drops minimize
inflammation and the risk of infection following retina surgery. Alphagan drop is
used to control eye pressure. Atropine minimizes pain caused by swelling and
inflammation, following retina surgery.
Option C: An eye patch or shield is applied to protect the eye and prevent any
further detachment. Protective shields should be worn for at least a week and
guidelines should be followed closely to ensure incisions heal properly without
disruption.
Option D: Positioning, activity restrictions, and eye patches hinder the client in
the performance of activities of daily living, and the client needs the nurse’s
assistance with these activities. Activity must be restricted, and patients should
refrain from bending and heavy lifting (2-10 lb. limit).
Option E: Coughing is not encouraged because this can increase intraocular
pressure and harm the client. Coughing has been implicated in the development
of spontaneous choroidal hemorrhage in the immediate postoperative period.
