Respiratory- NCLEX 5th Edition Test With 100% Verified Solutions |
Graded A+
1. A cardiac monitor alarm sounds, and a Assess the client.
nurse notes a straight line on the monitor
screen. The immediate nursing action is
to:
2. A clinic nurse is assisting in caring for a -Get plenty of rest.
client whose chief complaint is the pres- -Take antipyretics for fever.
ence of flu-like symptoms. Which recom- -Increase intake of liquids.
mendation by the nurse is therapeutic?
Select all that apply.
3. A nurse is performing nasotracheal suc- Coughing occurs with suction-
tioning of a client. The nurse interprets ing
that the client is adequately tolerating the
procedure if which of the following ob-
servations are made?
4. A nurse is reading the results of the Man- Negative
toux skin test for a client who has no doc-
umented health problems. The site has
no induration and a 1-mm area of ec-
chymosis. The nurse interprets that the
result is:
5. A nurse is told that an assigned client will Enables the client to speak
have a fenestrated tracheostomy tube in-
serted. The nurse prepares the client for
the procedure, knowing that this type of
tube:
6. The chest x-ray report for a client states Just under the left clavicle
that the client has a left apical pneumoth-
orax. The nurse would monitor the status
of breath sounds in that area by placing
the stethoscope:
7. A nurse is assigned to care for a client On the side
after a left pneumonectomy. Which one of
,Respiratory- NCLEX 5th Edition Test With 100% Verified Solutions |
Graded A+
the follow positions would be contraindi-
cated for this client?
8. The nurse is preparing a list of home care -Activities should be resumed
instructions for the client who has been gradually.
hospitalized and treated for tuberculosis. -A sputum culture is needed
Choose the instructions that the nurse every 2 to 4 weeks once med-
will include on the list. Select all that ap- ication therapy is initiated.
ply. -Respiratory isolation is not
necessary because family
members have already been
exposed.
-Cover the mouth and nose
when coughing or sneezing and
confine used tissues to plastic
bags.
9. A nurse is performing nasopharyngeal Check the amount of suction
suctioning on a client and suddenly pressure being applied.
notes the presence of bloody secretions.
The nurse would first:
10. A nurse is assisting in admitting a client skin color
to the emergency department with sus-
pected carbon monoxide poisoning. The
nurse understands that which of the fol-
lowing manifestations is least reliable for
determining the oxygenation status of
this client?
11. A client arrives in the emergency depart- Places the client in
ment with an episode of status asthmati- high-Fowler's position
cus. The nurse first:
12. A nurse is monitoring a client with a The chest tube is functioning as
closed chest tube drainage system and expected.
notes fluctuation of the fluid level in
the water-seal chamber during inspira-
tion and expiration. On the basis of this
finding, the nurse determines that:
, Respiratory- NCLEX 5th Edition Test With 100% Verified Solutions |
Graded A+
13. A nurse is providing endotracheal suc- Discontinue suctioning until the
tioning to a client who is mechanically client is stabilized and monitor
ventilated when the client becomes rest- vital signs.
less and tachycardic. What should the
nurse do?
14. A nurse is monitoring a client following a Shortness of breath and tra-
motor vehicle accident. The nurse deter- cheal deviation
mines the need to prepare for chest tube
insertion when the client exhibits:
15. A nurse is performing nasotracheal suc- Coughing occurs with suction-
tioning of a client. The nurse determines ing
that the client is adequately tolerating the
procedure if which observation is made?
16. A nurse is collecting data from a client Several weeks to months
who is experiencing the typical clinical
manifestations of tuberculosis (TB). The
nurse would expect the client to report
having symptoms of fatigue and cough
that have been present for
17. A nurse is suctioning an adult client Stop the suctioning procedure
through a tracheostomy tube. During
the procedure, the nurse notes that
the client's oxygen saturation by pulse
oximetry is 89%. The nurse would:
18. A nurse is caring for the restless client Oral airway
who keeps biting down on an orotracheal
tube. The nurse uses which of the follow-
ing to prevent the client from obstructing
the airway with the teeth?
19. A nurse is planning care for a client Instruct the client not to move
whose oxygenation is being monitored the sensor.
by a pulse oximeter. Which of the fol-
lowing is important to include to ensure
Graded A+
1. A cardiac monitor alarm sounds, and a Assess the client.
nurse notes a straight line on the monitor
screen. The immediate nursing action is
to:
2. A clinic nurse is assisting in caring for a -Get plenty of rest.
client whose chief complaint is the pres- -Take antipyretics for fever.
ence of flu-like symptoms. Which recom- -Increase intake of liquids.
mendation by the nurse is therapeutic?
Select all that apply.
3. A nurse is performing nasotracheal suc- Coughing occurs with suction-
tioning of a client. The nurse interprets ing
that the client is adequately tolerating the
procedure if which of the following ob-
servations are made?
4. A nurse is reading the results of the Man- Negative
toux skin test for a client who has no doc-
umented health problems. The site has
no induration and a 1-mm area of ec-
chymosis. The nurse interprets that the
result is:
5. A nurse is told that an assigned client will Enables the client to speak
have a fenestrated tracheostomy tube in-
serted. The nurse prepares the client for
the procedure, knowing that this type of
tube:
6. The chest x-ray report for a client states Just under the left clavicle
that the client has a left apical pneumoth-
orax. The nurse would monitor the status
of breath sounds in that area by placing
the stethoscope:
7. A nurse is assigned to care for a client On the side
after a left pneumonectomy. Which one of
,Respiratory- NCLEX 5th Edition Test With 100% Verified Solutions |
Graded A+
the follow positions would be contraindi-
cated for this client?
8. The nurse is preparing a list of home care -Activities should be resumed
instructions for the client who has been gradually.
hospitalized and treated for tuberculosis. -A sputum culture is needed
Choose the instructions that the nurse every 2 to 4 weeks once med-
will include on the list. Select all that ap- ication therapy is initiated.
ply. -Respiratory isolation is not
necessary because family
members have already been
exposed.
-Cover the mouth and nose
when coughing or sneezing and
confine used tissues to plastic
bags.
9. A nurse is performing nasopharyngeal Check the amount of suction
suctioning on a client and suddenly pressure being applied.
notes the presence of bloody secretions.
The nurse would first:
10. A nurse is assisting in admitting a client skin color
to the emergency department with sus-
pected carbon monoxide poisoning. The
nurse understands that which of the fol-
lowing manifestations is least reliable for
determining the oxygenation status of
this client?
11. A client arrives in the emergency depart- Places the client in
ment with an episode of status asthmati- high-Fowler's position
cus. The nurse first:
12. A nurse is monitoring a client with a The chest tube is functioning as
closed chest tube drainage system and expected.
notes fluctuation of the fluid level in
the water-seal chamber during inspira-
tion and expiration. On the basis of this
finding, the nurse determines that:
, Respiratory- NCLEX 5th Edition Test With 100% Verified Solutions |
Graded A+
13. A nurse is providing endotracheal suc- Discontinue suctioning until the
tioning to a client who is mechanically client is stabilized and monitor
ventilated when the client becomes rest- vital signs.
less and tachycardic. What should the
nurse do?
14. A nurse is monitoring a client following a Shortness of breath and tra-
motor vehicle accident. The nurse deter- cheal deviation
mines the need to prepare for chest tube
insertion when the client exhibits:
15. A nurse is performing nasotracheal suc- Coughing occurs with suction-
tioning of a client. The nurse determines ing
that the client is adequately tolerating the
procedure if which observation is made?
16. A nurse is collecting data from a client Several weeks to months
who is experiencing the typical clinical
manifestations of tuberculosis (TB). The
nurse would expect the client to report
having symptoms of fatigue and cough
that have been present for
17. A nurse is suctioning an adult client Stop the suctioning procedure
through a tracheostomy tube. During
the procedure, the nurse notes that
the client's oxygen saturation by pulse
oximetry is 89%. The nurse would:
18. A nurse is caring for the restless client Oral airway
who keeps biting down on an orotracheal
tube. The nurse uses which of the follow-
ing to prevent the client from obstructing
the airway with the teeth?
19. A nurse is planning care for a client Instruct the client not to move
whose oxygenation is being monitored the sensor.
by a pulse oximeter. Which of the fol-
lowing is important to include to ensure
