NCLEX Respiratory Questions
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Question 1 of 5.
Based on Virchow's Triad, select which patients below are at RISK for the development of a deep vein thrombosis? Select all that apply:
A. A 55-year-old male with hyperlipidemia and diabetes.
B. A 70-year-old female with severe sepsis.
C. A 25-year-old male who uses intravenous drugs.
D. A 65-year-old female who is post-op day 1 after joint replacement surgery.
Explanation: Virchow's Triad details the THREE factors for blood clot formation within the vessel. Remember 'SHE': Stasis of Venous Blood, Hypercoagulability (means excessive coagulability), Endothelial damage. Patients who experience sepsis are at risk for hypercoagulability of the blood. Patients who use IV drugs damage the endothelial lining of the veins and this can lead to blood clot formation. Patients who've had joint replacement surgery are at risk for blood clots due to stasis of venous circulation etc.
Question 2 of 5.
The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication?
A. Muscle weakness.
B. Purulent sputum.
C. Nuchal rigidity.
D. Intermittent loss of muscle control.
Explanation: Nuchal rigidity (C) suggests meningitis, a life-threatening sinusitis complication. Muscle weakness (A) and loss of control (D) are unrelated, and purulent sputum (B) is more typical of respiratory infections.
Question 3 of 5.
The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)?
A. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain.
B. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication.
C. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad.
D. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
Explanation: Purulent drainage post-Caldwell-Luc (C) suggests infection, requiring experienced assessment. Antral irrigation (A), tonsillectomy refusal (B), and antibiotics (D) are less complex.
Question 4 of 5.
The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?
A. Vitamin C, 2,000 mg daily.
B. Strict bedrest.
C. Humidification of the air.
D. Decongestant therapy.
Explanation: Vitamin C (A) is an alternative therapy for colds, with unproven efficacy. Bedrest (B), humidification (C), and decongestants (D) are standard supportive measures.
Question 5 of 5.
The client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
A. Administer the ordered oral antibiotic immediately (STAT).
B. Order the meal tray to be delivered as soon as possible.
C. Obtain a sputum specimen for culture and sensitivity.
D. Have the unlicensed assistive personnel weigh the client.
Explanation: Obtaining sputum culture (C) before antibiotics ensures accurate pathogen identification, a priority. Antibiotics (A) follow, meals (B) and weight (D) are less urgent.