NCLEX Test Bank: Respiratory
NCLEX, Neuro NCLEX, GI NCLEX,
Orthopadic NCLEX, Cardio, GI
NCLEX
1.A client admitted to the hospital for treatment of active tuberculosis (TB).
The LPN/LVN reinforces teaching about TB. Which statement by the client
indicates to the LPN/LVN that further teaching is necessary?
o Answer: "I will remain in isolation for at least 6 weeks."
o Rationale: Clients with active TB are placed in airborne precautions, but
they are not necessarily in isolation for six weeks. They are no longer
considered contagious after they have had three negative sputum
smears, which usually occurs within 2-4 weeks of starting effective
therapy. The other statements are correct: TB treatment lasts 6 months,
patients should cover their mouth and nose, and they will always have a
positive skin test.
2. A nurse is caring for four clients. Which client should the nurse assess FIRST?
o Answer: A client with a chest tube who has continuous bubbling in the
water seal chamber.
o Rationale: Continuous bubbling in the water seal chamber indicates an
air leak. This can lead to a tension pneumothorax or complete lung
collapse, a life-threatening airway/breathing issue.
3. What is the priority nursing action for a client with active pulmonary
tuberculosis?
o Answer: Implement airborne precautions.
o Rationale: TB requires airborne precautions, which includes a negative
pressure room, an N95 respirator, and limiting client transport. The
client should wear a surgical mask when outside the room.
4. Which measure prevents Deep Vein Thrombosis in bedridden patients? (From
a list including Propped up position, Compression Bandage, Incentive
Spirometry, Back Massage)
o Answer: Compression Bandage (or, more accurately, compression
stockings/devices are used).
o Rationale: While the specific wording is "Compression Bandage," the
correct intervention to prevent DVT is the use of sequential
compression devices (SCDs) or anti-embolism stockings to promote
venous return.
,5. What breathing pattern is associated with Diabetic Ketoacidosis (DKA)?
o Answer: Kussmaul's Respiration.
o Rationale: Kussmaul's respirations are deep, rapid breaths. The body
attempts to blow off excess carbon dioxide to compensate for
metabolic acidosis, which is a hallmark of DKA.
6. A client reports chest pressure and has a BP of 150/90. After nitroglycerin 0.4
mg SL, BP is 100/60. What should the nurse do next?
o Answer: Document vital signs and continue to monitor the client.
o Rationale: A drop in blood pressure is an expected effect of
nitroglycerin due to vasodilation. The nurse should document the
finding and continue to monitor the client's hemodynamic status,
especially if the client is asymptomatic.
7. A nurse is preparing to discharge a client who speaks a different primary
language. Which action is essential for ensuring safe discharge teaching?
o Answer: Use a certified medical interpreter to explain the discharge
instructions.
o Rationale: Federal laws mandate the use of certified medical
interpreters for clients with limited English proficiency to ensure
accurate, unbiased medical communication. Family members are not
reliable for medical interpretation.
8. A client is experiencing anaphylaxis. What is the priority nursing intervention?
o Answer: Ensure a patent airway.
o Rationale: The ABCs (Airway, Breathing, Circulation) are the priority. In
anaphylaxis, airway edema can rapidly compromise breathing, making
airway management the top priority.
9. A client with emphysema has:
o Answer: High compliance. [From previous search results]
o Rationale: Emphysema destroys alveolar walls and elastic tissue,
reducing elastic recoil. This makes the lungs easier to distend, which is
defined as high compliance.
10. A patient is 1-day post-op from a total knee replacement and reports
lightheadedness. Hemoglobin dropped from 12 to 9 g/dL. What is the priority
action?
o Answer: Notify the healthcare provider and prepare for possible blood
transfusion.
o Rationale: A significant drop in hemoglobin post-operatively with
lightheadedness suggests active bleeding. The provider must be
notified, and blood products may be needed.
,Neuro (Questions 11-20)
11. The initial blood pressure of a patient with a head injury is 124/80 mm Hg. As
his condition worsens, which blood pressure indicates a significantly widened
pulse pressure?
o Answer: 160/100 mm Hg.
o Rationale: A widening pulse pressure (increasing difference between
systolic and diastolic pressures) is a late sign of increased intracranial
pressure (ICP). The initial pulse pressure was 44 (124-80). The reading
160/100 has a pulse pressure of 60, which is greater.
12. The most common cause of airway obstruction in an unresponsive victim is:
o Answer: Tongue.
o Rationale: In an unresponsive person, the tongue loses muscle tone
and can fall back, obstructing the pharynx and airway.
13. A client is diagnosed with a right-sided stroke with dysphagia. Which action
reflects appropriate care? (Select all that apply.)
o Answer: Assess the client's ability to swallow; Offer the client
scrambled eggs; Turn off the television.
o Rationale: The nurse must assess swallowing ability. Scrambled eggs
are a soft, easy-to-swallow food. Reducing distractions (TV off) helps
the client focus on safe swallowing. The client should be positioned
with HOB elevated 90 degrees, not 25. Food should be placed on the
strong (left) side, not the affected (right) side.
14. A client is being treated for heart failure with diuretic therapy. Which finding
best indicates improvement?
o Answer: There are fewer crackles heard when auscultating the client's
lungs.
o Rationale: Crackles (rales) are caused by fluid in the lungs (pulmonary
edema). A decrease in crackles indicates that the diuretic is effectively
reducing fluid overload.
15. The perception of noise or ringing in the ears is otherwise termed as:
o Answer: Tinnitus.
o Rationale: Tinnitus is the perception of ringing or noise in the ears.
16. Which component is NOT part of the Glasgow Coma Scale?
o Answer: Best sensory response.
o Rationale: The GCS assesses three components: Eye Opening, Verbal
Response, and Motor Response. Sensory response is not a component.
17. The P wave in an ECG represents:
o Answer: Atrial depolarisation.
, o Rationale: The P wave represents the electrical activation
(depolarization) of the atria, which leads to atrial contraction.
18. A patient develops a seizure while sitting in a chair. The first action the nurse
must take is:
o Answer: Ease the patient into the floor.
o Rationale: The priority is to protect the patient from injury. Gently
easing them to the floor prevents a fall from the chair. Restraining them
or inserting an airway are contraindicated.
19. A client with a head injury is exhibiting confusion and twitching. This could be
a sign of:
o Answer: Severe uremia or electrolyte imbalances.
o Rationale: Confusion and twitching in a client with end-stage renal
disease (ESRD) are signs of severe uremia or electrolyte imbalances like
hyperkalemia or hypocalcemia, which can rapidly progress to seizures
or cardiac arrest.
20. Which clinical manifestation does the nurse assess as a typical reaction to
long-term phenytoin sodium (Dilantin) therapy?
o Answer: Gum hyperplasia.
o Rationale: Gingival hyperplasia (overgrowth of gum tissue) is a well-
known side effect of long-term phenytoin use.
GI (Questions 21-25)
21. A client is returned to the unit after a paracentesis. It is most important for the
nurse to ask which question?
o Answer: "Are you feeling dizzy?"
o Rationale: Removing a large volume of ascitic fluid can cause a rapid
shift in intravascular volume, leading to hypotension. Dizziness is a key
symptom of hypotension and should be assessed immediately.
22. Patient on anticoagulant drugs reports bleeding gum, black tarry stools. It is a
manifestation of:
o Answer: Drug overdose.
o Rationale: Bleeding gums and black, tarry stools (melena) are signs of
bleeding, indicating the anticoagulant dose is too high (overdose).
23. Which nursing intervention would be the most helpful in prevention of a
stress ulcer related to a burn in a three-year-old child?
o Answer: Administer cimetidine (Tagamet) as ordered.
NCLEX, Neuro NCLEX, GI NCLEX,
Orthopadic NCLEX, Cardio, GI
NCLEX
1.A client admitted to the hospital for treatment of active tuberculosis (TB).
The LPN/LVN reinforces teaching about TB. Which statement by the client
indicates to the LPN/LVN that further teaching is necessary?
o Answer: "I will remain in isolation for at least 6 weeks."
o Rationale: Clients with active TB are placed in airborne precautions, but
they are not necessarily in isolation for six weeks. They are no longer
considered contagious after they have had three negative sputum
smears, which usually occurs within 2-4 weeks of starting effective
therapy. The other statements are correct: TB treatment lasts 6 months,
patients should cover their mouth and nose, and they will always have a
positive skin test.
2. A nurse is caring for four clients. Which client should the nurse assess FIRST?
o Answer: A client with a chest tube who has continuous bubbling in the
water seal chamber.
o Rationale: Continuous bubbling in the water seal chamber indicates an
air leak. This can lead to a tension pneumothorax or complete lung
collapse, a life-threatening airway/breathing issue.
3. What is the priority nursing action for a client with active pulmonary
tuberculosis?
o Answer: Implement airborne precautions.
o Rationale: TB requires airborne precautions, which includes a negative
pressure room, an N95 respirator, and limiting client transport. The
client should wear a surgical mask when outside the room.
4. Which measure prevents Deep Vein Thrombosis in bedridden patients? (From
a list including Propped up position, Compression Bandage, Incentive
Spirometry, Back Massage)
o Answer: Compression Bandage (or, more accurately, compression
stockings/devices are used).
o Rationale: While the specific wording is "Compression Bandage," the
correct intervention to prevent DVT is the use of sequential
compression devices (SCDs) or anti-embolism stockings to promote
venous return.
,5. What breathing pattern is associated with Diabetic Ketoacidosis (DKA)?
o Answer: Kussmaul's Respiration.
o Rationale: Kussmaul's respirations are deep, rapid breaths. The body
attempts to blow off excess carbon dioxide to compensate for
metabolic acidosis, which is a hallmark of DKA.
6. A client reports chest pressure and has a BP of 150/90. After nitroglycerin 0.4
mg SL, BP is 100/60. What should the nurse do next?
o Answer: Document vital signs and continue to monitor the client.
o Rationale: A drop in blood pressure is an expected effect of
nitroglycerin due to vasodilation. The nurse should document the
finding and continue to monitor the client's hemodynamic status,
especially if the client is asymptomatic.
7. A nurse is preparing to discharge a client who speaks a different primary
language. Which action is essential for ensuring safe discharge teaching?
o Answer: Use a certified medical interpreter to explain the discharge
instructions.
o Rationale: Federal laws mandate the use of certified medical
interpreters for clients with limited English proficiency to ensure
accurate, unbiased medical communication. Family members are not
reliable for medical interpretation.
8. A client is experiencing anaphylaxis. What is the priority nursing intervention?
o Answer: Ensure a patent airway.
o Rationale: The ABCs (Airway, Breathing, Circulation) are the priority. In
anaphylaxis, airway edema can rapidly compromise breathing, making
airway management the top priority.
9. A client with emphysema has:
o Answer: High compliance. [From previous search results]
o Rationale: Emphysema destroys alveolar walls and elastic tissue,
reducing elastic recoil. This makes the lungs easier to distend, which is
defined as high compliance.
10. A patient is 1-day post-op from a total knee replacement and reports
lightheadedness. Hemoglobin dropped from 12 to 9 g/dL. What is the priority
action?
o Answer: Notify the healthcare provider and prepare for possible blood
transfusion.
o Rationale: A significant drop in hemoglobin post-operatively with
lightheadedness suggests active bleeding. The provider must be
notified, and blood products may be needed.
,Neuro (Questions 11-20)
11. The initial blood pressure of a patient with a head injury is 124/80 mm Hg. As
his condition worsens, which blood pressure indicates a significantly widened
pulse pressure?
o Answer: 160/100 mm Hg.
o Rationale: A widening pulse pressure (increasing difference between
systolic and diastolic pressures) is a late sign of increased intracranial
pressure (ICP). The initial pulse pressure was 44 (124-80). The reading
160/100 has a pulse pressure of 60, which is greater.
12. The most common cause of airway obstruction in an unresponsive victim is:
o Answer: Tongue.
o Rationale: In an unresponsive person, the tongue loses muscle tone
and can fall back, obstructing the pharynx and airway.
13. A client is diagnosed with a right-sided stroke with dysphagia. Which action
reflects appropriate care? (Select all that apply.)
o Answer: Assess the client's ability to swallow; Offer the client
scrambled eggs; Turn off the television.
o Rationale: The nurse must assess swallowing ability. Scrambled eggs
are a soft, easy-to-swallow food. Reducing distractions (TV off) helps
the client focus on safe swallowing. The client should be positioned
with HOB elevated 90 degrees, not 25. Food should be placed on the
strong (left) side, not the affected (right) side.
14. A client is being treated for heart failure with diuretic therapy. Which finding
best indicates improvement?
o Answer: There are fewer crackles heard when auscultating the client's
lungs.
o Rationale: Crackles (rales) are caused by fluid in the lungs (pulmonary
edema). A decrease in crackles indicates that the diuretic is effectively
reducing fluid overload.
15. The perception of noise or ringing in the ears is otherwise termed as:
o Answer: Tinnitus.
o Rationale: Tinnitus is the perception of ringing or noise in the ears.
16. Which component is NOT part of the Glasgow Coma Scale?
o Answer: Best sensory response.
o Rationale: The GCS assesses three components: Eye Opening, Verbal
Response, and Motor Response. Sensory response is not a component.
17. The P wave in an ECG represents:
o Answer: Atrial depolarisation.
, o Rationale: The P wave represents the electrical activation
(depolarization) of the atria, which leads to atrial contraction.
18. A patient develops a seizure while sitting in a chair. The first action the nurse
must take is:
o Answer: Ease the patient into the floor.
o Rationale: The priority is to protect the patient from injury. Gently
easing them to the floor prevents a fall from the chair. Restraining them
or inserting an airway are contraindicated.
19. A client with a head injury is exhibiting confusion and twitching. This could be
a sign of:
o Answer: Severe uremia or electrolyte imbalances.
o Rationale: Confusion and twitching in a client with end-stage renal
disease (ESRD) are signs of severe uremia or electrolyte imbalances like
hyperkalemia or hypocalcemia, which can rapidly progress to seizures
or cardiac arrest.
20. Which clinical manifestation does the nurse assess as a typical reaction to
long-term phenytoin sodium (Dilantin) therapy?
o Answer: Gum hyperplasia.
o Rationale: Gingival hyperplasia (overgrowth of gum tissue) is a well-
known side effect of long-term phenytoin use.
GI (Questions 21-25)
21. A client is returned to the unit after a paracentesis. It is most important for the
nurse to ask which question?
o Answer: "Are you feeling dizzy?"
o Rationale: Removing a large volume of ascitic fluid can cause a rapid
shift in intravascular volume, leading to hypotension. Dizziness is a key
symptom of hypotension and should be assessed immediately.
22. Patient on anticoagulant drugs reports bleeding gum, black tarry stools. It is a
manifestation of:
o Answer: Drug overdose.
o Rationale: Bleeding gums and black, tarry stools (melena) are signs of
bleeding, indicating the anticoagulant dose is too high (overdose).
23. Which nursing intervention would be the most helpful in prevention of a
stress ulcer related to a burn in a three-year-old child?
o Answer: Administer cimetidine (Tagamet) as ordered.
