NCLEX-PN Test #20 1 — Questions and Answers
Question 1: A patient's pulse oximetry reading is 88% on room air. What is the nurse's priority action?
- Document the finding and recheck in 1 hour
- Notify the physician and apply supplemental oxygen as ordered (Correct answer)
- Encourage the patient to breathe deeply and recheck in 15 minutes
- Reposition the probe and assume the reading is inaccurate
Correct answer: Notify the physician and apply supplemental oxygen as ordered
A SpO2 of 88% is below the normal range (95–100%) and indicates hypoxemia. The nurse must notify the provider and apply supplemental oxygen per protocol or order. Delaying action or attributing the reading to probe error without clinical assessment is unsafe.
Question 2: A nurse is caring for a patient receiving oxygen via a non-rebreather mask at 15 L/min. Which assessment finding requires immediate intervention?
- SpO2 of 97%
- Respiratory rate of 14 breaths per minute
- Reservoir bag deflating completely on inspiration (Correct answer)
- Patient reports the mask feels tight
Correct answer: Reservoir bag deflating completely on inspiration
The reservoir bag on a non-rebreather mask should never fully deflate during inspiration. If it does, the flow rate is insufficient to meet the patient's inspiratory demand and the patient is breathing room air, defeating the purpose of the high-flow device. The flow rate should be increased immediately.
Question 3: A nurse is suctioning a patient with a tracheostomy. Which action reflects correct technique?
- Apply suction continuously while inserting the catheter
- Insert the catheter until resistance is met, then apply suction while withdrawing with a rotating motion (Correct answer)
- Suction for up to 45 seconds to ensure airway clearance
- Use the same suction catheter for repeated passes without rinsing
Correct answer: Insert the catheter until resistance is met, then apply suction while withdrawing with a rotating motion
Correct tracheostomy suction technique involves inserting the catheter without suction until resistance is met (or to the recommended depth), then applying intermittent suction while withdrawing with a rotating motion. Each pass should not exceed 10–15 seconds to prevent hypoxia. The catheter should be rinsed between passes.
Question 4: A patient with COPD is admitted with an exacerbation. Their ABG results show pH 7.31, PaCO2 58 mmHg, HCO3 26 mEq/L. How should the nurse interpret these results?
- Respiratory alkalosis with metabolic compensation
- Metabolic acidosis with respiratory compensation
- Respiratory acidosis with normal metabolic response (Correct answer)
- Normal ABG within acceptable limits
Correct answer: Respiratory acidosis with normal metabolic response
pH 7.31 = acidosis; elevated PaCO2 58 mmHg = respiratory cause (CO2 retention); HCO3 26 mEq/L is slightly elevated but within normal range, indicating early or minimal compensation. This is respiratory acidosis — consistent with COPD exacerbation and CO2 retention.
Question 5: A nurse is caring for a patient post-bronchoscopy. Which assessment finding should concern the nurse most immediately?
- Mild sore throat
- Hoarse voice immediately after the procedure
- Stridor and increasing respiratory distress (Correct answer)
- Patient drowsy but arousable from sedation
Correct answer: Stridor and increasing respiratory distress
Stridor after bronchoscopy indicates laryngospasm or significant airway edema — a life-threatening complication requiring immediate intervention. While a sore throat and hoarseness are expected, stridor with respiratory distress demands emergency response including notification of the provider and preparation for airway management.
Question 6: A nurse is providing care for a patient on mechanical ventilation. The high-pressure alarm sounds on the ventilator. What is the nurse's first action?
- Silence the alarm and continue monitoring
- Increase the tidal volume setting
- Manually ventilate the patient with a bag-valve mask while assessing the cause (Correct answer)
- Turn off the ventilator and contact respiratory therapy
Correct answer: Manually ventilate the patient with a bag-valve mask while assessing the cause
When a ventilator alarm sounds, the first priority is the patient's safety. If the cause is not immediately apparent, the nurse should disconnect the patient from the ventilator and manually ventilate with a bag-valve mask while assessing for the cause (secretions, kinked tubing, biting the tube, bronchospasm, etc.).
NCLEX-PN Test #20 1
A patient's pulse oximetry reading is 88% on room air.
What is the nurse's priority action?