NCLEX-PN Test #8 1 — Questions and Answers
Question 1: A client with COPD is admitted with acute exacerbation. The nurse prepares to administer supplemental oxygen. Which oxygen delivery method and flow rate is most appropriate for this client?
- Nonrebreather mask at 10–15 L/min
- Simple face mask at 8 L/min
- Nasal cannula at 1–2 L/min (Correct answer)
- Venturi mask at 6 L/min with 35% FiO2
Correct answer: Nasal cannula at 1–2 L/min
Clients with COPD may rely on hypoxic drive to breathe. High-flow oxygen can eliminate this drive and cause respiratory depression. Low-flow oxygen via nasal cannula at 1–2 L/min is appropriate to maintain SpO2 at 88–92%. A Venturi mask is also acceptable for precise FiO2 delivery, but the standard starting approach is low-flow nasal cannula.
Question 2: A nurse is suctioning a client's tracheostomy. During suctioning, the client's SpO2 drops from 97% to 84%. Which action should the nurse take first?
- Increase the suction pressure and complete the procedure quickly
- Remove the suction catheter and apply 100% oxygen (Correct answer)
- Pause briefly, then resume suctioning
- Call for emergency intubation
Correct answer: Remove the suction catheter and apply 100% oxygen
A significant drop in SpO2 during tracheal suctioning indicates hypoxia. The nurse must immediately remove the suction catheter, apply 100% oxygen, and allow the client to recover before attempting suctioning again. Suctioning should never be applied for more than 10–15 seconds and should be preceded and followed by oxygenation.
Question 3: A nurse is performing auscultation on a client admitted with pneumonia. Crackles (rales) are heard in the right lower lobe. Which finding would the nurse most likely also observe?
- Barrel chest and prolonged expiration
- Tachypnea and decreased breath sounds in the affected lobe (Correct answer)
- Wheezing on inspiration throughout all lung fields
- Stridor and use of accessory muscles at rest
Correct answer: Tachypnea and decreased breath sounds in the affected lobe
Pneumonia causes consolidation of the affected lobe, leading to decreased or absent breath sounds in the area, along with crackles from fluid in the alveoli. Tachypnea is a compensatory response. Barrel chest and prolonged expiration are COPD findings; wheezing suggests bronchospasm; stridor indicates upper airway obstruction.
Question 4: A postoperative client refuses to use the incentive spirometer, stating, 'It hurts too much to breathe deeply.' What is the nurse's best response?
- Excuse the client from using it and document the refusal
- Instruct the client to use the spirometer as ordered or risk pneumonia
- Offer pain medication 30 minutes before incentive spirometry and splint the incision with a pillow (Correct answer)
- Perform chest physiotherapy instead of incentive spirometry
Correct answer: Offer pain medication 30 minutes before incentive spirometry and splint the incision with a pillow
Postoperative pain is a barrier to deep breathing, which increases the risk of atelectasis and pneumonia. The most effective approach is to premedicate the client for pain (peaking before therapy) and teach splinting (supporting the incision with a pillow or folded blanket) to reduce discomfort during deep breathing exercises.
Question 5: A nurse is caring for a client on mechanical ventilation. The high-pressure alarm is sounding. Which condition is least likely to cause this alarm?
- The client is biting on the endotracheal tube
- A disconnection in the ventilator circuit (Correct answer)
- Secretions accumulating in the airway
- The client is coughing or fighting the ventilator
Correct answer: A disconnection in the ventilator circuit
A high-pressure alarm indicates increased resistance in the airway or circuit (e.g., secretions, biting, bronchospasm, coughing). A circuit disconnection or leak would trigger a low-pressure alarm, not a high-pressure one. This is the least likely cause of a high-pressure alarm.
Question 6: A client with asthma is admitted with an acute exacerbation. The nurse notes the client is using accessory muscles to breathe, has an expiratory wheeze, and SpO2 is 90%. Which action takes priority?
- Apply oxygen and administer the prescribed bronchodilator (albuterol) via nebulizer (Correct answer)
- Place the client in a supine position and obtain a peak flow reading
- Administer IV corticosteroids before any other intervention
- Draw an ABG and wait for results before treating
Correct answer: Apply oxygen and administer the prescribed bronchodilator (albuterol) via nebulizer
During an acute asthma exacerbation, the priority is to reverse bronchospasm and correct hypoxia. Applying supplemental oxygen and administering a short-acting beta-agonist bronchodilator (albuterol) are the first-line interventions. Supine positioning worsens dyspnea. Corticosteroids are secondary. Waiting for labs delays critical treatment.
NCLEX-PN Test #8 1
A client with COPD is admitted with acute exacerbation.
The nurse prepares to administer supplemental oxygen.
Which oxygen delivery method and flow rate is most appropriate for this client?