Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) G, Exercises of Nursing

Download Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) G and more Exercises Nursing in PDF only on Docsity! Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) The most important action the nurse should do before and after suctioning a client is: a. Placing the client in a supine postion b. Making sure that suctioning takes only 10-15 seconds c. Evaluating for clear breath sounds d. Hyperventilating the client with 100% oxygen - correct answers ✅d. Hyperventilating the client with 100% oxygen The position of a conscious client during suctioning is: a. Fowler's b. Supine position c. Side-lying d. Prone - correct answers ✅a. Fowler's Position a conscious person who has a functional gag reflex in the semi fowler's position with the head turned to one side for oral Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you. Presence of overdistended and non-functional alveoli is a condition called: a. Bronchitis b. Emphysema c. Empyema d. Atelectasis - correct answers ✅Answer: B. An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung. 23. The accumulation of fluids in the pleural space is called: Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site. - correct answers ✅Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) 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. - correct answers ✅b. Grasp the retention sutures to spread the opening. A nurse is caring for a male 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 of 24 breaths/min - correct answers ✅Answer A. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) The nurse reports stridor to the physician immediately. This is a high- pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breathe sounds c. The presence of a barrel chest d. A sucking sound at the site of injury - correct answers ✅Answer B. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum - correct answers ✅Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement. A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) c. 6 L/min d. 10 L/min - correct answers ✅Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination. - correct answers ✅Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds - correct answers ✅Answer C. Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds. - correct answers ✅Answer C. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis - correct answers ✅Answer A. In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids - correct answers ✅Answer D. After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration - correct answers ✅Answer D. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and Sx include - pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation - shallow respirations - splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome - correct answers ✅Answer A. Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate - correct answers ✅Answer D. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. T his is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) this client has which of the following forms of chronic airflow limitations? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis - correct answers ✅Answer A. The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss - correct answers ✅Answer B. The client with tuberculosis USUALLY experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Describe Tachypnea - correct answers ✅respirations > 35 clinical significance/contributing factors: - respiratory failure - response to fever - anemia - pain - respiratory infection - anxiety (emergencies SNS system kicks in) Identify initial assessment findings for a patient with EARLY STAGE LEFT sided heart failure - correct answers ✅- fatigue - breathlessness - dizziness - confusion as a result of tissue hypoxia from the diminished CO Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse? a. She has a history of smoking. b. She is using accessory muscles to breathe. b. She is in pending respiratory failure. c. Nothing. This is normal. - correct answers ✅c. Nothing. This is normal. The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? a. Left of the sternum, third intercostal space Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) b. Above the clavicles c. Below the scapula d. Right of the sternum, sixth intercostal space - correct answers ✅b. Above the clavicles The apex of each lung is slightly superior to the inner third of the clavicle. A client with a strained trapezius muscle complains of having occasional shortness of breath. What might be the reason for this symptom? a. The strained muscle is an accessory muscle of respiration. b. The diaphragm muscle is also injured. c. There is an undiagnosed heart problem. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) The mother of a four-year-old child tells the nurse, "I think there's something wrong with him; his chest is round like a ball." Which of the following would be an appropriate response for the nurse to make to the mother? a. I see what you mean. That seems odd. b. The chest of a child appears round and is normal. c. I wouldn't worry about that. d. Did you tell the doctor about this? - correct answers ✅b. The chest of a child appears round and is normal. After examining a 75-year-old male client, the nurse writes down "barrel chest." What does this finding suggest? a. The client has a history of smoking. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) b. The client has osteoporosis. c. The client has long-standing respiratory disease. d. This is a change associated with aging. - correct answers ✅d. This is a change associated with aging. A 57-year-old client tells the nurse, "I need two to three pillows to sleep." How should this information be documented? a. Two to three pillow orthopnea b. Dyspnea on excursion c. Resting apnea d. Dyspnea at rest - correct answers ✅a. Two to three pillow orthopnea Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) The client tells the nurse he sometimes coughs up "thick yellow mucous." What does this information suggest to the nurse? a. He might have an allergy. b. He might have a fungal infection. c. He might have episodic lung infections. d. He might have tuberculosis. - correct answers ✅c. He might have episodic lung infections Rationale: The color and odor of any mucus is associated with specific diseases or problems. Green or yellow mucus often signals a lung infection. a 48-year-old client doesn't smoke cigarettes yet is demonstrating signs of lung irritation. Which of the following questions could help with the assessment of this client? Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) a. This client is hyperventilating. b. This client is in a diabetic coma. c. This client has pneumonia. d. This is seen in aging people, people with heart failure, and people who have suffered brain damage. - correct answers ✅d. This is seen in aging people, people with heart failure, and people who have suffered brain damage. In planning a patient education session, the nurse sees one area of focus for Healthy People 2010 is chronic obstructive pulmonary disease (COPD). Which of the following information should the nurse include in the education session to address this focus area? a. Screening for environmental triggers b. Smoking cessation Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) c. Develop action plans d. Identify those at risk - correct answers ✅b. Smoking cessation B - correct answers ✅besides high blood pressure values, what other signs and symptoms may the nurse observe if hypertension is present? A) Unexplained pain and hyperactivity B) Headache, flushing of the face, and nosebleed C) Dizziness, mental confusion, and mottled extremities D) Restlessness and dusky or cyanotic skin that is cool to the touch D - correct answers ✅Which of the following vlues for vital signs would the nurse address first? A) Heart rate = 72 beats per minute B) Respiration rate = 28 breaths per minute C) Blood pressure = 160/86 Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) D) Oxygen saturation by pulse oximetry = 89% E) Temperature = 37.2° C (99° F), tympanic D - correct answers ✅An 82-year-old widower brought via ambulance is admitted to the emergency department with complaints of shortness of breath, anorexia, and malaise. He recently visited his health care provider and was put on an antibiotic for pneumonia. The client indicates that he also takes a diuretic and a beta blocker, which helps his "high blood." Which vital sign value would take priority in initiating care? A) Respiration rate = 20 breaths per minute B) Oxygen saturation by pulse oximetry = 92% C) Blood pressure = 138/84 D) Temperature = 39° C (102° F), tympanic Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) C) Tell the client it is very important to end the conversation so the nurse can count respirations. D) Document the respiration rate as "deferred" and measure the rate later, since the talking client is obviously not in respiratory distress. D - correct answers ✅Delegation of some tasks may become one of the decisions the nurse will make while on duty. For which of the following clients would it be most appropriate for unlicensed assistive personnel to measure the client's vital signs? A) A client who recently started taking an antiarrhythmic medication B) A client with a history of transfusion reactions who is receiving a blood transfusion C) A client who has frequently been admitted to the unit with asthma attacks D) A client who is being admitted for elective surgery who has a history of stable hypertension Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) D - correct answers ✅The client has an oral temperature of 39.2° C (102.6° F). What are the most appropriate nursing interventions? A) Provide an alcohol sponge bath and monitor laboratory results. B) Remove excess clothing, provide a tepid sponge bath, and administer an analgesic. C) Provide fluids and nutrition, keep the client's room warm, and administer an analgesic. D) Reduce external coverings and keep clothing and bed linens dry; administer antipyretics as ordered. D - correct answers ✅The hypothalamus controls body temperature. The anterior hypothalamus controls heat loss, and the posterior hypothalamus controls heat production. What heat conservation mechanisms will the posterior hypothalamus initiate when it senses that the client's body temperature is lower than comfortable? A) Vasodilation and redistribution of blood to surface vessels Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) B) Sweating, vasodilation, and redistribution of blood to surface vessels C) Vasoconstriction, sweating, and reduction of blood flow to extremities D) Vasoconstriction, reduction of blood flow to extremities, and shivering C - correct answers ✅The nurse's documentation indicates that a client has a pulse deficit of 14 beats. The pulse deficit is measured by: A) Subtracting 60 (bradycardia) from the client's pulse rate and reporting the difference B) Subtracting the client's pulse rate from 100 (tachycardia) and reporting the difference C) Assessing the apical pulse and the radial pulse for the same minute and subtracting the difference D) Assessing the apical pulse and 30 minutes later assessing the carotid pulse and subtracting the difference Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) 1, 5, 2, 4, 3 - correct answers ✅Place the vital signs in order of priority for your nursing interventions: 1) SpO2= 89% 2) BP= 160/86 mmHG 3) Temperature= 37.3 (99.4) 4) HR= 72 BPM 5) RR= 28 BrPM 1, 2, 4, 7 - correct answers ✅82 yr old admitted via ambulance to ER with shortness of breath, anorexia, and malaise. He recently visited the health care center and is on antibiotic for pneumonia. He is also on a diuretic, beta-adrergic blocker, which helps his "high blood". He has a temperature of 38.2 (100.8) via temporal artery. What additional assessment data is needed in planning intervention for the patients infection ? (choose all that apply) 1. HR 2. Skin turgor Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) 3. Smoking history 4. Allergies to antibiotics 5. Recent BM's 6. BP in right arm 7. Client's normal temperature 8. BP in distal extremity Which of the following laboratory values would you expect in a client experiencing prolonged immobility? 1. Elevated calcium 2. Decreased sodium 3. Elevated hemoglobin 4. Elevated potassium - correct answers ✅1. Elevated calcium A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Which of the following should the nurse document in the medical record? 1. Rebound hypotension 2. Positional hypotension 3. Orthostatic hypotension 4. Central venous hypotension - correct answers ✅3. Orthostatic hypotension The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to: 1. prevent varicose veins 2. prevent muscular atrophy 3. ensure joint mobility and prevent contractures 4. facilitate the return of venous blood to the heart - correct answers ✅4. facilitate the return of venous blood to the heart Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A client had a left- sided cerebral vascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enternal feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? 1. Hematuria 2. Unilateral neglect 3. Limited ROM in the right hip 4. Coughing up moderate amount clear, thin sputum - correct answers ✅1. Hematuria A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. A trapeze bar Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) 2. A small transfer board 3. A powered standing-assist device 4. An ankle foot orthotic (AFO) for the affected foot - correct answers ✅2. A small transfer board The nurse is caring for a client who has right-sided weak-ness. The nurse needs to help the client walk. What should the nurse order from the home medical supply company to help the client move from the bed to the chair? 1. Hold the client's left hand while walking 2. Hold the client's right hand while walking 3. Put a gait belt on the client and provide support on the left side 4. Put a gait belt on the client and provide support on the right side - correct answers ✅4. Put a gait belt on the client and provide support on the right side Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Before transferring a client from the bed to a stretcher, which assessment data does the nurse need to gather? (choose all that apply) 1. The client's weight 2. How cooperative the client is 3. The client's nutritional status 4. The presence of intravenous (IV) tubes - correct answers ✅1. The client's weight 2. How cooperative the client is 4. The presence of intravenous (IV) tubes THE NURSE SHOULD USE EXTREME CAUTION WHEN APPLYING HEAT THERAPY TO WHICH OF THE FOLLOWING PATIENTS: A UNCONSCIOUS B HIGH PAIN SENSITIVITY C VENOUS ULCER Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A THE NURSE ADMINISTERING THE DRUG B PHARMACIST WHO DISPENSED C NURSE MANAGER D PHYSICIAN WHO WROTE THE ORDER - correct answers ✅A WHICH ONE OF THE NUTRITIONAL GUIDELINES SHOULD THE NURSE GIVE A WOMAN IN HER 2ND TRIMESTER OF PREGNANCY A EAT NORMAL NUMBER OF CALORIES BUT INCREASE FRUITS AND VEGETABLES B MAINTAIN REG CALORIE INTAKE, BUT TAKE SUPPLEMENTS C EAT AS MUCH AS YOU CAN D MORE CALORIES AND HIGH IN NUTRIENTS - correct answers ✅D PATIENT TELLS NURSE "I CANT GET ANY SLEEP AROUND HERE" NURSES FIRST RESPONSE: A ADD MORE CARBS TO DINNER Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) B ASSESS FACTORS THAT PATIENT BELIEVES TO BE PROBLEM C TEACH PATIENT RELAXATION TECHNIQUES AND REDUCE NOISE ON THE UNIT D OBTAIN PRN ODER FOR SEDATIVE - correct answers ✅B THE DRESSING CHANGE ON A DEEP UPPER-ARM WOUND IS PAINFUL FOR THE PATIENT. WHEN PREPARING A CARE PLAN FOR THE PATIENT, THE NURSE WILL INCORPORATE WHICH OF THE FOLLOWING MEASURES: A ADMINISTER ANALGESIC IMMEDIATELY BEFORE DRESSING CHANGE B PERFORM DRESSING CHANGE WHEN PATIENT IS FATIGUED FROM PT C PERFORM DRESSING CHANGE DURING MEALTIME SO PATIENT IS DISTRACTED D ADMINISTER ANALGESIC 30-45 MIN BEFORE DRESSING CHANGE - correct answers ✅D Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) THE PHYSICIANS ADMITTING ORDERS INDICATE THAT THE PATIENT IS TO BE PLACED IN A FOWLERS POSITION, UPON POSITIONING THIS PATIENT, HOW MUCH WILL THE NURSE ELEVATE THE HEAD? A 15 B 90 C 45-60 D 30 - correct answers ✅C PRIOR TO STARTING A TUBE FEEDING, THE NURSE ASSESSES THE PH AND COLOR OF THE PATIENT'S GASTRIC CONTENTS AND RECEIVES A PH READING OF 6.2 AND THE ASPIRATE IS OFF-WHITE COLOR. A STOMACH B SMALL INTESTINE C COLON D RESPIRATORY TRACT - correct answers ✅D Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) AT WHAT POINT SHOULD THE NURSE DO THE 3 CHECKS OF MEDICATION ADMINISTRATION? A AS THE NURSE REACHES FOR THE DRUG PACKAGE B WHEN REVIEWING THE PATIENT;S MAR C AT THE BEGINNING OF SHIFT D AFTER RETRIEVING THE DRUG - correct answers ✅A What are the 10 Rights of Medication Administration - correct answers ✅Medication Assessment Dose Documentation Route Patient Education Timing Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Evaluation Refusal (MADDRPETER) blood+water - correct answers ✅Serosanguinous blood - correct answers ✅Sanguinous brown green or yellow - correct answers ✅Purulent True or False The character of the exudate, in amount, color and odor, can help to identify the exact nature of the infection - correct answers ✅True Stage I pressure Ulcer - correct answers ✅Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators Stage II pressure Ulcer - correct answers ✅Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage III pressure Ulcer - correct answers ✅Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage IV pressure Ulcer - correct answers ✅Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with this type of pressure ulcer. Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) The evening nurse reviews the nursing documentation in the male client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis - correct answers ✅D The nurse has delegated administration of 10am medications to an LPN/LVN. At 10:15am, the nurse notes none of the medications have been administer yet. Which is the best action for the nurse to take? a) ask another LPN/LVN assigned to the unit to help administer medications b) begin administering the medications Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) c) report he situation to the head nurse d) ask the LPN/LVN to give the nurse a status report - correct answers ✅A A nurse on a pediatric unit is preparing the assignment for the evening shift. The unit employs unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? a) setting up Bryant's traction b) completing the FACES pain scale for a child with sickle cell crisis c) obtaining post-operative vital signs on a client status post- tonsillectomy d) setting up an intravenous therapy pump - correct answers ✅A An operating room nurse has just finished setting up a sterile field for a kidney transplant surgery. She gets word that the donor organ will Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) not be available for another thirty minutes. Which of the following is the best course of action? A) Personally watch the sterile field to ensure that it is not broken. B) Place cones or barriers in front of the main OR doors. C) Place sterile drapes over all surfaces. D) Thirty minutes is too long. The sterile field will need to be broken and reestablished later - correct answers ✅A When teaching a patient about wound healing, the nurse should tell the patient: Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days. True False - correct answers ✅false Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms. True False - correct answers ✅true Which of the following patients have risk factors for developing a wound infection? (Select all that apply.) A) An 80-year-old man who has a burn B) A 17-year-old patient who has a metal fragment lodged in his thigh Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) C) A 30-year-old female who had an episiotomy after childbirth D) A patient receiving chemotherapy who has a surgical incision E) A patient with peripheral vascular disease and an ulcer on the heel - correct answers ✅ABDE How can you determine a patient's history of allergies? (Select all that apply.) A) By looking at the patient's allergy bracelet B) By looking at the MAR C) By asking the patient D) By looking at the front of the chart E) By administering a dose and monitoring the patient's response - correct answers ✅ABCD Heat or Cold? Increased Capillary Permeability - correct answers ✅Heat Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Heat or Cold? Relieves Pain - correct answers ✅Cold Heat or Cold? Increased Blood Viscosity - correct answers ✅Cold Heat or Cold? Decreased Blood Viscosity - correct answers ✅Heat Heat or Cold? Reduced cell metabolism - correct answers ✅Cold Heat or Cold? Vasodilation - correct answers ✅Heat Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Heat or Cold? Increases Blood flow - correct answers ✅Heat Heat or Cold? Reduces O2 needs of tissues - correct answers ✅Cold Heat or Cold? Promotes blood coagulation at injury site - correct answers ✅Cold Heat or Cold? Improves delivery of antibiotics to wound - correct answers ✅Heat Heat or Cold? Decreases Spasmodic Pain - correct answers ✅Heat Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Advantages of Oral, Buccal and Sublingual Routes - correct answers ✅-- Conveinent and comfortable --Economical --Sometimes produce local or systemic effects --rarely cause anxiety Disadvantages of Oral, Buccal and Sublingual Routes - correct answers ✅--GI irritation Advantages of Parenteral Routes - correct answers ✅--can be used when oral drugs are contraindicated --more rapid absorption --epidural provides excellent pain control Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Disadvantages of Parenteral Routes - correct answers ✅--introducing infection --tissue damage --more expensive --quicker absorption=quicker adverse reactions --more painful Advantages for Skin - correct answers ✅--local effect --painless --limited side effects Disadvantages for Skin - correct answers ✅--absorption occurs too rapid over abrasions --medications overall absorb slowly through this route Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) place on conjuctival sac btw iris and lower lid gently pull eyelid over disk carefully pinch disk to remove from patient's eye What is the purpose of a spacer? - correct answers ✅it helps the medication reach the lungs used in children and elderly helps avoid mouth fungus,nervousness and other side effects NREM stage 1 - correct answers ✅A few minutes, light sleep, easily aroused, gradual reduction in vital signs NREM stage 2 - correct answers ✅10-20 min, can be awakened w/effort, deeper relaxation Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) NREM stage 3 - correct answers ✅15-30 min, early phase of deep sleep, snoring, relaxed muscle tone, little/no physical movement, difficult to arouse NREM stage 4 - correct answers ✅15-30 min, shortens toward morning, deep sleep, sleep-walking, sleep-talking, bed-wetting may occur REM sleep - correct answers ✅a recurring sleep state during which dreaming occurs Circadian Rhythm - correct answers ✅the biological clock; regular bodily rhythms that occur on a 24-hour cycle Functions of Sleep - correct answers ✅Restoration, reducing fatigue,stabilizing mood, improving blood flow to the brain, increasing protein synthesis, maintaining the disease-fighting mechanisms of the Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) immune system,promoting cellular growth and repair, improving the capacity for learning and memory storage Factors affecting sleep - correct answers ✅physical illness drugs and substances emotional stress environment lifestyle exercise and fatigue food and caloric intake sound transduction of pain - correct answers ✅process that begins in the periphery when pain-producing stimulus send an impulse across a peripheral nerve fiber Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) nonblanchable hyperemia - correct answers ✅redness of the skin due to dilation of the superficial capillaries. The redness persists when pressure is applied to the area, indicating tissue damage Unstageable - correct answers ✅full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar partial thickness wound repair - correct answers ✅- inflammatory response (24hrs.) - epithelial proliferation/migration - reestablishment of epidermal layers full thickness wound repair - correct answers ✅- inflammatory (up to 3 days) - proliferative (3-24 days) - remodeling (up to 1 yr.) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) evisceration - correct answers ✅wound separation with protrusion of organs fistula - correct answers ✅abnormal passageway between two organs or between an internal organ and the body surface dihiscence - correct answers ✅rupture separion of one or more layers of a wound. incision - correct answers ✅surgical cut or wound produced by a sharp instrument abrasion - correct answers ✅Scraping or wearing away of the skin by friction; irritation Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) contusion - correct answers ✅an injury to underlying tissues without breaking the skin and is characterized by discoloration and pain open wound - correct answers ✅an injury in which the skin is interrupted, exposing the tissue beneath closed wound - correct answers ✅wound that involves underlying tissue without break in the skin puncture wound - correct answers ✅An open wound that tears through the skin and destroys underlaying tissues. A penetrating puncture wound can be shallow or deep. A perforating puncture wound has both an entrance and an exit wound. hematoma - correct answers ✅the collection of blood under the skin as the result of blood escaping into the tissue from damaged blood vessels. bruise Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) d. Vietnam War - correct answers ✅c. World War II Which of the following phrases describes one of the purposes of the ANA's nursing's social policy statement? a. to describe the nurse as a dependent caregiver b. To provide standards for nursing educational programs c. to regulate nursing research d. to describe nursing's values and social responsiblity - correct answers ✅d. The nursing's social policy statement describes the values and social responsibility of nursing A school nurse is teaching a class of junior-high students about the effects of smoking. This educational program will meet which of the aims of nursing? a. promoting health b. preventing illness Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) c. restoring health d. facilitating coping with disability or death - correct answers ✅b. Educational programs can reduce the risk of illness by teaching good health habits Which of the following nursing degrees prepares a nurse for advanced practice as a clinical specialist or nurse practitioner? a. LPN b. ADN c. BSN d. Master's - correct answers ✅d. A Master's degree prepares advanced practice nurses. Which nursing organization was the first international organization of professional women? a. ICN Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions) b. ANA c. NLN d. NSNA - correct answers ✅a. The ICN, founded in 1899, was the first international organization of professional women. What is the purpose of the ANA's Scope and Standards of Practice? a. To describe the ethical responsibility of nurses b. To define the activities that are special and unique to nursing c. To establish nursing as an independent and free standing profession d. To regulate the practice of nursing - correct answers ✅b. The ANA's Scope and Standards of Practice define the activities of nurses that are specific and unique to nursing. What type of authority regulates the practice of nursing? a. International standards and codes b. Federal guidelines and regulations Combo with Respiratory System NCLEX Exam Questions with Solutions (100% Correct Answers) Graded A+ 2024 June (500+ Questions)