Nclex 6 Respiratory Exam Questions With Correct Answers.
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Course
NCLEX
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NCLEX
Nclex 6 Respiratory Exam Questions With
Correct Answers.
4. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees
Rationale:
To facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the
bed, leaning over a bedside table, wit...
Nclex 6 Respiratory Exam Questions With
Correct Answers.
4. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees
Rationale:
To facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the
bed, leaning over a bedside table, with the feet supported on a stool or lying in bed on the
unaffected side, with the head of the bed elevated 45 degrees (Fowler's position). Options 1, 2,
and 3 are incorrect. - answer✔✔A client is being prepared for a thoracentesis. The nurse should
assist the client to which position for the procedure?
1. Sims' position, with the head of the bed flat
2. Prone, with the head turned to the side supported by a pillow
3. Lying in bed on the affected side, with the head of the bed elevated 45 degrees
4. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees
4. Discontinue suctioning until the client is stabilized and monitor vital signs.
Rationale:
If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another
abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The
nurse would also notify the registered nurse. It is also important to monitor the vital signs and the
pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department
and health care provider may need to be notified. There is no data in the question that indicates
that the rapid response team needs to be notified. - answer✔✔The nurse is providing
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
endotracheal suctioning to a client who is mechanically ventilated when the client becomes
restless and tachycardic. Which action should the nurse take?
1. Notify the Rapid Response Team.
2. Finish the suctioning as quickly as possible.
3. Contact the respiratory department to suction the client.
4. Discontinue suctioning until the client is stabilized and monitor vital signs.
3. 50 mL of drainage in the drainage-collection chamber
4. The drainage system is maintained below the client's chest.
5. An occlusive dressing is in place over the chest-tube insertion site.
6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
Rationale:
The bubbling of water in the water-seal chamber indicates air drainage from the client. This is
usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur
during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may
indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the
water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may
indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into
the pleural space. Gentle (not vigorous) bubblin - answer✔✔The nurse is assisting with
monitoring the functioning of a chest-tube drainage system in a client who just returned from the
recovery room after a thoracotomy with wedge resection. Which findings should the nurse
expect to note? Select all that apply.
1. Excessive bubbling in the water-seal chamber
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
2. Vigorous bubbling in the suction-control chamber
3. 50 mL of drainage in the drainage-collection chamber
4. The drainage system is maintained below the client's chest.
5. An occlusive dressing is in place over the chest-tube insertion site.
6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
3. Continue to monitor, because this is an expected finding.
Rationale:
The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent
drainage system. With normal breathing, the water level rises with inspiration and falls with
expiration. The apparatus and all connections must remain airtight at all times, and the drainage
is never emptied because of the risk of disruption in the closed system, which can result in lung
collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not
told to hold his or her breath. - answer✔✔The nurse is assigned to assist with caring for a client
who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber.
Based on this observation, which action would be appropriate?
1. Empty the drainage.
2. Encourage the client to deep breathe.
3. Continue to monitor, because this is an expected finding.
4. Encourage the client to hold his or her breath periodically.
4. Perform Valsalva's maneuver.
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
Rationale:
When the chest tube is removed, the client is asked to perform Valsalva's maneuver (i.e., take a
deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is
taped in place. An alternative instruction is to ask the client to take a deep breath and hold the
breath while the tube is removed. Options 1, 2, and 3 are incorrect client instructions. -
answer✔✔The nurse is assigned to assist the health care provider with the removal of a chest
tube. The nurse should reinforce instructing the client to do which during this process?
1. Stay very still.
2. Exhale forcefully.
3. Inhale and exhale quickly.
4. Perform Valsalva's maneuver.
2. Be sure all connections remain airtight.
3. Be sure all connections are taped and secure.
5. Monitor closely for tubing that is kinked or obstructed by the weight of the client.
Rationale:
Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental
dislodgment of the tube when the client moves. The chest tube system is not opened and emptied
because a closed system must be maintained; if the system is opened, lung collapse can occur.
Options 2, 3, and 5 are appropriate interventions for the plan of care for a client with a chest
tube. - answer✔✔The nurse is assisting in planning care for a client with a chest tube. The nurse
should suggest to include which interventions in the plan? Select all that apply.
1. Pin the tubing to the bed linens.
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