NCLEX style review questions

Created by amick231 

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In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation?

1) Apex of the lungs
2) Alveolar-capillary membrane
3) Cilia in the bronchi
4) Right and left main-stem bronchi

Answer:
2) Alveolar-capillary membrane

Rationale:
The lungs are composed of millions of alveoli. The alveoli are tiny air sacs with thin walls surrounded by a fine network of capillaries. Gases easily pass back and forth between the alveoli and capillaries. It is at the alveolar-capillary membrane that inhaled air comes in contact with the blood of the pulmonary circulation.

Respiratory function involves, in addition to the respiratory system, which three body systems?

1) Neurological, endocrine, and cardiovascular
2) Cardiovascular, neurological, and integumentary
3) Cardiovascular, neurological, and musculoskeletal
4) Musculoskeletal, cardiovascular, and endocrine

Answer:
3) Cardiovascular, neurological, and musculoskeletal

Rationale:
The musculoskeletal and neurological systems regulate the movement of air into and out of the respiratory system. The cardiovascular system transports oxygen and carbon dioxide, which are exchanged in the lungs.

The nurse is caring for an adolescent with a history of asthma. The patient is currently being treated for acute bronchitis. A thorough nursing assessment of the patient's pulmonary status will include: Select all that apply.

1) Skin color and temperature
2) Auscultation of breath sounds
3) Testing of cough reflex
4) Chest x-ray

Answer:
1) Skin color and temperature
3) Testing of cough reflex

Rationale:
Auscultation of the lungs will detect any adventitious breath sounds (e.g., wheezing) that may be present with asthma and bronchitis. Evaluation of skin color and temperature are indirect methods to assess tissue oxygenation. A chest x-ray requires a physician order and is not a part of the nursing assessment. The cough reflex should be assessed in clients with decreased levels of consciousness.

What assessment findings might the nurse expect to see in a patient experiencing hypoxia? Select all that apply.

1) Altered level of consciousness
2) Peripheral pitting edema
3) Cyanosis of skin and mucous membranes
4) Weak or absent peripheral pulses

Answer:
1) Altered level of consciousness
3) Cyanosis of skin and mucous membranes

Rationale:
Hypoxia leads to decreased oxygenation of organs and tissues. To determine adequacy of tissue oxygenation, you must assess both circulation and tissue/organ function. An altered level of consciousness may result from hypoxic central nervous system tissue. Poor peripheral circulation is characterized by weak or absent pulses; pale, ashen, or cyanotic skin and mucous membranes; and cool skin temperature. Peripheral edema does not result from hypoxia.

Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry?

1) Patient will refrain from movement while monitored in order to ensure accurate readings.
2) Oxygen saturation will remain at 80% to 90% during hospitalization.
3) Patient will report pain as less than 3 on a scale of 1 to 10 during monitoring.
4) Oxygen saturation will remain at 95% to 100% while monitored.

Answer:
4) Oxygen saturation will remain at 95% to 100% while monitored.

Rationale:
Normal oxygen saturation is 95% to 100%. Values of 94% or less are considered abnormal in healthy people and should be investigated to determine the cause. Although movement may affect oximetry monitoring, it is essential that patients move and turn in order to prevent atelectasis. Pulse oximetry is a noninvasive form of monitoring that involves placing a probe on a part of the body where capillary blood flow is near the surface (e.g., a nail bed, earlobe, nose, or forehead). It does not cause pain.

A 45-year-old woman presents to the emergency department with complaints of shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth. Her respirations are deep, at a rate of 28 per minute. Her lungs are clear with good aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2 of 110 and PCO2 of 29. Based on this assessment, an appropriate nursing diagnosis would be:

1) Ineffective Airway Clearance
2) Decreased Cardiac Output
3) Impaired Gas Exchange
4) Hypocarbia

Answer:
3) Impaired Gas Exchange

Rationale:
Hypocarbia (hypocapnia) is a low level of dissolved CO2 in the blood because of hyperventilation. In most cases, blood oxygen levels remain normal. Severe hypocarbia stimulates the nervous system, leading to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips. This patient is experiencing hypocarbia; however, this is a medical diagnosis. A corresponding nursing diagnosis is Impaired Gas Exchange. There is no evidence of difficulty maintaining a clear airway or problems with cardiac pumping; therefore, Ineffective Airway Clearance and Decreased Cardiac Output are not good choices.

The nurse is caring for an older adult woman who was admitted 3 days ago following a cerebrovascular accident. She has had trouble swallowing and has been placed on aspiration precautions. Care of this patient will include the following: Select all that apply.

1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink
2) Break or crush her pills (if appropriate) before administration
3) Provide only thin, clear liquids
4) Keep suction setup available at all times

Answer:
1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink
3) Provide only thin, clear liquids

Rationale:
Aspiration is a risk for patients with a decreased level of consciousness, diminished gag or cough reflex, or difficulty with swallowing. You should keep suction setup available for routine and emergency use. Keeping the head of the bed elevated will also help to prevent aspiration. Breaking or crushing pills will make it easier for her to swallow her medications. Thin, clear liquids are more likely to be aspirated than are thickened liquids, and there is no indication for clear liquids.

While caring for a young adult on a mechanical ventilator, the ventilator alarms sound. On entering the patient's room, the nurse notes that he is agitated and his skin is ashen and diaphoretic. His pulse oximetry shows an oxygen saturation of 78%. The nurse is unable to identify any obvious mechanical problems with the ventilator. The first step the nurse should take is to:

1) assess his breath sounds.
2) call the respiratory therapist to troubleshoot the problem.
3) manually ventilate him with an Ambu-bag.
4) contact the physician.

Answer:
3) manually ventilate him with an Ambu-bag.

Rationale:
All the actions listed are appropriate and necessary. However, if you cannot quickly identify and correct a problem with the ventilator, you must ensure adequate ventilation until the problem can be identified and corrected. Your immediate response should be to manually ventilate the patient with an Ambu-bag. Your colleagues should assist you by troubleshooting the problem, assessing breath sounds, and notifying the physician.

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