NCLEX Questions
A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate?
"Blocked nasal passages impair the sense of smell."
A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported?
Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments?
"I cannot give Legionnaires' disease to other people." Rationale: Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription.
The nursing instructor is reviewing the pathophysiology of influenza. The nursing instructor determines there is a need for further teaching if the nursing student makes which statement regarding influenza? 1) Influenza A infects only humans. 2) Influenza is primarily spread through droplet contact. 3) There are four types of influenza, known as influenza A, B, C, or D, but influenza C or D do not cause significant illness in humans. 4) Influenza A types are named based on two characteristic surface proteins, known as hemagglutinin and neuraminidase."
"Influenza A infects only humans." Rationale: Influenza is a highly contagious respiratory viral infection that is spread through infected droplets via inhalation of aerosolized particles or from direct contact with contaminated surfaces. Therefore, option 2 is a correct statement. Influenza is divided into four serotypes, or influenza A, B, C, or D, with each type having different characteristics. Of the four types, influenza C and D do not cause significant illness in humans; therefore, option 3 is an accurate statement. Influenza A is further classified by two characteristic surface proteins, known as the hemagglutinin protein and neuraminidase protein and are named based on their H and N type (for example, H1N1). Therefore, option 4 is a correct statement. Influenza A can infect both animals and humans and is the cause of both the swine and avian flu. Therefore, option 1 is an inaccurate statement and requires further teaching from the nursing instructor.
A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?
"It will enter the right main bronchus if inserted too far." Rationale: If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur..
The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful?
"My nails may become clubbed." Rationale: A client with COPD will have clubbing of the nails, described as an angle between the nail plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as iron-deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal depression across the nail beds is caused by medical problems, such as acute, severe illness and isolated periods of severe malnutrition.
Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1) Reduce fluid intake to less than 1500 mL/day. 2) Teach diaphragmatic and pursed-lip breathing. 3) Encourage alternating activity with rest periods. 4) Teach the client techniques of chest physiotherapy. 5) Keep the client in a supine position as much as possible.
2) Teach diaphragmatic and pursed-lip breathing 3) Encourage alternating activity with rest periods 4) Teach the client techniques of chest physiotherapy
The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. Answer Options 1) U waves 2) Widened T wave 3) Prominent U wave 4) Prolonged QT interval 5) Prolonged ST segment
4) Prolonged QT interval 5) Prolonged ST segment Rationale: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment.
The nurse is caring for a client with dysphagia who is diagnosed with pneumonia and prescribed a honey-thick diet. The nurse is preparing to assist the client with eating. Which is the priority nursing action?
Allow the client frequent rest breaks during the meal.
The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
Aspiration of gastric contents occurs during suctioning Rationale: Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents.
A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse would take which action?
Determine whether there are any disconnections in the ventilator tubing Rationale: The low-pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea. High-pressure alarms can be triggered by increased airway resistance, which can occur with excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?
Diminished breath sounds
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse would assess the client for which expected finding?
Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?
Flushing Rationale: Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.
A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority?
Inability to clear the airway related to inability to expectorate sputum. Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.
The nurse is reviewing the pathophysiology of influenza and the various strains of the disease. The nurse would correctly identify H3N2 as which type of influenza?
Influenza A
A client in the primary health care provider's (PHCP's) office for an annual well visit asks the nurse about the differences between influenza and the common cold (viral rhinitis). The nurse would make which response to the client?
Influenza has a rapid symptom onset, while common cold symptoms appear gradually
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse would ask the client whether the client wears which item during periods of exposure to silica particles?
Mask
The nurse in the emergency department is reviewing laboratory results for a client with carbon monoxide poisoning. The client's carboxyhemoglobin level is 25%. How would the nurse interpret the severity of carbon monoxide poisoning?
Moderate poisoning Rationale: Carbon monoxide is a colorless, odorless, and tasteless gas that is released into the air due to combustion. Carbon monoxide has a higher affinity for hemoglobin than oxygen, forming carboxyhemoglobin and thereby impeding the body's ability to oxygenate tissues. Laboratory testing to determine the severity of carbon monoxide poisoning is a serum carboxyhemoglobin level. A normal carbon monoxide, or carboxyhemoglobin, level is 1% to 10%. Mild poisoning is indicated by carbon monoxide levels ranging from 11% to 20%. Moderate poisoning is indicated by carbon monoxide levels ranging from 21% to 40%. Severe poisoning is indicated by carbon monoxide levels ranging from 41% to 60%. Lastly, fatal poisoning is indicated by carbon monoxide levels ranging from 61% to 80%. Therefore, a carboxyhemoglobin level of 25% indicates moderate carbon monoxide poisoning.
The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How would the nurse interpret the result?
Negative
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding?
Pain, especially with inspiration. Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include shallow respirations, splinting or guarding the chest protectively to minimize chest movement, pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
The nurse instructs a client with chronic obstructive pulmonary disease (COPD) to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?
Promote carbon dioxide elimination Rationale: 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.
A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder?
The inflamed pleurae cannot glide against each other as they normally do. Rationale: Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration.
The nursing instructor is reviewing the various complications of a tracheostomy. The nursing instructor determines teaching has been effective if the nursing student correctly identifies which of the following conditions as tracheal dilation and cartilage erosion?
Tracheomalacia Rationale: Several complications can arise from the creation of a tracheostomy related to increased cuff pressure or tube positioning that result in impaired tissue integrity. Some of these complications include tracheomalacia, tracheal stenosis, TEF, and trachea-innominate artery fistula. Tracheal stenosis describes narrowing of the tracheal lumen due to growth of scar tissue in response to tissue irritation from the cuff. TEF describes erosion of the posterior tracheal wall from continuous, excessive cuff pressure that creates an opening between the trachea and anterior esophagus. Trachea-innominate artery fistula is a medical emergency that results from lateral misplacement of the tracheostomy tube that causes pressure and subsequent necrosis and erosion of the innominate artery. Tracheomalacia is tracheal dilation and cartilage erosion from continuous cuff pressure.
The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?
Twitching Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include Paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
