NCLEX Questions Respiratory
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Question 1 of 5.
A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that:
A. The patient will need to immediately be placed in droplet precautions and started on a medication regime.
B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided.
C. The patient will need an IGRA test to help differentiate between a latent tuberculosis infection versus an active tuberculosis infection.
D. The patient will need to repeat the skin test in 48-72 hours to confirm the results.
Explanation: A positive PPD result does NOT necessarily mean the patient has an active infection of TB. The patient will need a chest x-ray and sputum culture to determine if mycobacterium tuberculosis is present and then treatment will be based on those results. The IGRA test does NOT differentiate between LTBI or an active TB infection. Patients are placed in airborne precautions (NOT droplet) if they have ACTIVE TB.
Question 2 of 5.
Which information should the nurse teach the client diagnosed with acute sinusitis?
A. Instruct the client to complete all the ordered antibiotics.
B. Teach the client how to irrigate the nasal passages.
C. Have the client demonstrate how to blow the nose.
D. Give the client samples of a narcotic analgesic for the headache.
Explanation: Completing antibiotics (A) ensures treatment of bacterial sinusitis, preventing resistance. Irrigation (B) is supportive, nose-blowing (C) is routine, and narcotics (D) are excessive for sinus headaches.
Question 3 of 5.
The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first?
A. Administer the narcotic analgesic intravenous push (IVP).
B. Perform gentle oral hygiene.
C. Place the client in semi-Fowler's position.
D. Assess the client's pain.
Explanation: Pain assessment (D) is the first step to determine severity and guide treatment. Narcotics (A), oral hygiene (B), and positioning (C) follow based on assessment.
Question 4 of 5.
Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
A. Feed a client who is postoperative tonsillectomy the first meal of clear liquids.
B. Encourage the client diagnosed with a cold to drink a glass of orange juice.
C. Obtain a throat culture on a client diagnosed with bacterial pharyngitis.
D. Escort the client diagnosed with laryngitis outside to smoke a cigarette.
Explanation: Encouraging juice intake (B) is within UAP scope and safe. Feeding post-tonsillectomy (A) risks bleeding, throat cultures (C) require training, and smoking (D) is contraindicated.
Question 5 of 5.
The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care?
A. Inspect the insertion line at the naris prior to instilling formula.
B. Elevate the head of the bed (HOB) after feeding the client.
C. Place the client in the Sims position following each feeding.
D. Change the dressing on the feeding tube every three (3) days.
Explanation: Elevating HOB post-feeding (B) prevents aspiration in PEG clients. Naris inspection (A) applies to NG tubes, Sims position (C) is not standard, and dressings (D) are changed PRN.
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