NCLEX-PN Test #20 1 Flashcards
6 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 NCLEX-PN Test #20 1 flashcards as text
A patient's pulse oximetry reading is 88% on room air. What is the nurse's priority action?
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.
A nurse is caring for a patient receiving oxygen via a non-rebreather mask at 15 L/min. Which assessment finding requires immediate intervention?
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.
A nurse is suctioning a patient with a tracheostomy. Which action reflects correct technique?
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.
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?
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.
A nurse is caring for a patient post-bronchoscopy. Which assessment finding should concern the nurse most immediately?
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.
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?
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.).