Adult Health II Respiratory NCLEX Questions

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Question 1 of 5.

The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?

A. Change dressing per institutional policy.
B. Culture drainage at insertion site.
C. Notify physician.
D. Position rolled towel under client's back, parallel to the spine.

Correct arrangement

C. Notify physician.
B. Culture drainage at insertion site.
A. Change dressing per institutional policy.
D. Position rolled towel under client's back, parallel to the spine.

Explanation: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 2 of 5.

When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:

A. Help keep him well hydrated.

B. Dissolve clots that he may have.

C. Prevent kidney failure.

D. Treat potential cardiac arrhythmias.

Explanation: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.

Question 3 of 5.

Alteplase recombinant, or tissue plasminogen activator (t-PA), is administered during the first 6 hours after onset of myocardial infarction (MI) to:

A. Control chest pain.

B. Reduce coronary artery vasospasm.

C. Control the arrhythmias associated with MI.

D. Revascularize the blocked coronary artery.

Explanation: t-PA dissolves clots in the coronary artery, restoring blood flow (revascularization) to the ischemic myocardium, critical within the first 6 hours of MI.

Question 4 of 5.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by:

A. Antispasmodic effects on the pericardium.

B. Causing an increased myocardial oxygen demand.

C. Vasodilation of peripheral vasculature.

D. Improved conductivity in the myocardium.

Explanation: Nitroglycerin causes vasodilation of peripheral and coronary vasculature, reducing preload and myocardial oxygen demand, relieving angina.

Question 5 of 5.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.

A. Becoming increasingly short of breath at rest.

B. Weight gain of 2 lb or more in 1 day.

C. High intake of sodium for breakfast.

D. Having to sleep sitting up in a reclining chair.

E. Weight loss of 2 lb in 1 day.

Explanation: Shortness of breath at rest (A), weight gain of 2 lb or more in 1 day (B), and sleeping sitting up (D) indicate worsening heart failure, requiring physician notification.