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71. Before weaning a client from a ventilator, which assessment parameter is most important for the nurse to review?
a) Fluid intake for the past 24 hours
b) Baseline arterial blood gas (ABG) levels
c) Prior outcomes of weaning
d) Electrocardiogram (ECG) results
72. The nurse is assessing the puncture site of the client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?
a) 15-mm induration
b) Reddened area
c) 10-mm induration
73. A client who under went surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first
a) Initiate oxygen therapy.
b) Administer a heparin bolus and begin an infusion at 500 units/hour.
c) Administer analgesics as ordered.
d) Perform nasopharyngeal suctioning.
74. A client with colorectal carcinoma is devastated after learning that the cancer has spread to the liver and lungs and the client has only a 5% chance surviving for 5 years. Which comment by the nurse would best help the client cope with this news?
a) "I've seen clients in your situation who have lived almost 20 years."
b) "It must be hard to hear that prognosis. Would it help you to talk to me or the chaplain?"
c) "This might be a good time to think about an advance directive in case you run into problems while you're here."
d) "Those are just numbers. You have to live each day fully and not worry about dying."
75. Inspiratory and expiratory stridor may be heard in a client who:
a) is experiencing an exacerbation of goiter
b) is experiencing an acute asthmatic attack.
c) has aspirated a piece of meat
d) has severe laryngotracheitis
Respiratory NCLEX Practice Questions
Answers and Rationale
- Before weaning a client from mechanical ventilation, it's most important to have a baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
- A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. The other options aren't positive reactions to the test and require no further evaluation.
- The client's signs and symptoms suggest pulmonary embolism. therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely prescribe an anticoagulant, such as heparin, or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.
- This response is most therapeutic because it encourages the client to express feelings and concerns. Options A and D offer false hope and reflect the nurse's empirical observations, not statistics. Option C is inappropriate because an informed person who isn't a member of the health care team should discuss (at the client's request) which level of care the client wishes to receive in case of an emergency.
- Inspiratory and expiratory stridor is a low-pitched crowing sound heard in client who have a foreign body obstructing the trachea or mainstem bronchi. Acute asthmatic attacks are characterized by wheezing. Goiter attacks and severe laryngotracheitis are associated with inspiratory stridor only.
After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:
Respiratory NCLEX Practice Questions (1-6)
Or proceed to the next set of questions:
Respiratory NCLEX Practice Questions (76-80)