Chronic Obstructive Pulmonary Disease (COPD) Answers and Rationals

Chronic Obstructive Pulmonary Disease (COPD) Answers and Rationals
01. Answer: c. Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

02. Answer: a. Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump into pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

03. Answer: a. The client’s problem is altered nutrition—specifically, less than required. The cause, as stated by the client, is the fatigue associated with the disease process. Activity intolerance is a likely diagnosis but is not related to the client’s nutritional problems. Weight loss is not a nursing diagnosis. Ineffective breathing pattern may be a problem, but this diagnosis does not specifically address the problem of weight loss described by the client.


04. Answer: a. Pneumonia is the most common complication of influenza, especially in the elderly. The development of a purulent cough and crackles may be indicative of a bacterial infection are not consistent with a diagnosis of influenza. These findings are not indicative of dehydration. Decongestants and bronchodilators are not typically prescribed for the flu.

05. Answer: d. A client recovering from an URI should report decreasing or no nasal discharge and obstruction. Daily fluid intake should be increase to more than 1 L every 24 hours to liquefy secretions. The temperature should be below 100*F (37.8*C) with no chills or diaphoresis. A productive cough with chest pain indicated pulmonary infection, not an URI.


06. Answer: b. As the severe asthma attack worsens, the client becomes fatigued and alveolar hypotension develops. This leads to carbon dioxide retention and hypoxemia. The client develops respiratory acidosis. Therefore, the PaCO2 level increase, the PaO2 level decreases, and the pH decreases, indicating acidosis.

07. Answer: a. Irregular heart rates should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on the beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, petal edema, or bradycardia.

08. Answer: b. The pH (7.50) reflects alkalosis, and the low PaCO2 indicated the lungs are involved. The client should immediately be placed on oxygen via mask so that the SaO2 is brought up to 95%. Encourage slow, regular breathing to decrease the amount of CO2 she is losing. This client may have pulmonary embolism, so she should be monitored for this condition (4), but it is not the first intervention. Sodium bicarbonate (3) would be given to reverse acidosis; mechanical ventilation (1) may be ordered for acute respiratory acidosis.

09. Answer: a. Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood.

10. Answer: b. Chronic hypoxia associated with COPD may stimulate excessive RBC production (polycythemia). This results in increased blood viscosity and the risk of thrombosis. The other nursing diagnoses are not applicable in this situation.

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Nclex RN Medication and IV Administration Q & A

 Nclex RN Medication and IV Administration Q & A
1.A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
a) 5 minutes.
b) 10 minutes.
c) 20 minutes.
d) 30 minutes.


2.A client is scheduled for an excretory urography at 10 a.m. An order directs the nurse to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at:
a) 7:30 a.m.
b) 8:30 a.m.
c) 9 a.m.
d) 9:30 a.m

3.A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:
a) place the client in a supine position and prepare to perform cardiopulmonary resuscitation.
b) place the client in high-Fowler's position and administer supplemental oxygen.
c) turn the client on his left side and place the bed in Trendelenburg's position.
d) position the client in the shock position with his legs elevated.

4.The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 ml/hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:
a) Discontinue the infusion.
b) Apply a warm soak to the site.
c) Stop the flow of solution temporarily.
d) Irrigate the needle with normal saline



5.Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should:
a) Administer TPN through a nasogastric or gastrostomy tube.
b) Handle TPN using strict aseptic technique.
c) Auscultate for bowel sounds prior to administering TPN.
d) Designate a peripheral intravenous (IV) site for TPN administration.

6.To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:
a) Avoid excessive sun exposure.
b) Follow a low-cholesterol diet.
c) Obtain extra rest.
d) Supplement the diet with pyridoxine (vitamin B6).

7.When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:
a) 15 degrees.
b) 30 degrees.
c) 45 degrees.
d) 90 degrees.

8.A woman is taking oral contraceptives. The nurse teaches the client to report which of the following danger signs?
a) Breakthrough bleeding.
b) Severe calf pain.
c) Mild headache.
d) Weight gain of 3 lb.

9.The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
a) Minimal leaking.
b) No swelling.
c) Tissue pallor.
d) Evidence of a bleb or wheal.

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Intervention for Hydrocephalus nursing diagnosis Hydrocephalus

Intervention for Hydrocephalus

a) Maintain bed rest with the head flat and monitor vital signs as indicated after the lumbar puncture.
Rationale: Changes in cerebrospinal fluid pressure may be a potential risk of herniation of the brain stem, which requires immediate medical treatment.

b) Monitor / record neurological status, such as GCS.
Rationale: Assessment of trend changes and the potential of increasing the level of awareness of ICT is very useful in determining the location, distribution / extent and progression of cerebral damage.

c) Monitor the frequency / heart rhythm and heart rate.
Rationale: Changes in the frequency, dysrhythmias and heart rate may occur, which reflects brain stem trauma in the absence of underlying heart disease.

d) Monitor breathing, note the pattern, the respiratory rhythm and respiratory frequency.
Rationale: This type of pattern is a sign of heavy breathing from an increase in ICT / cerebral areas affected.
e) Elevate the head of the bed about 15-45 degrees as indicated. Keep the patient’s head remains in neutral position.
Rationale: Increased venous outflow from the head to reduce ICT.
f) Monitor the GDA. Provide oxygen therapy as needed.
Rationale: The occurrence of acidosis may inhibit the entry of oxygen at the cellular level that aggravate cerebral ischemia.

g) Give the medication as indicated.

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Gastrointestinal Disorders RN-NCLEX Practice Question 2

1. A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid?
a)"The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity."
b) "The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration."
c) "The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach."
d) "The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption."

2. Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
a) The client will be maintained on bed rest for several days.
b) Ambulation is restricted by the presence of drainage tubes.
c) The operative incision is near the diaphragm.
d) The presence of a nasogastric tube inhibits deep breathing.

3. A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?
a) Lean beef.
b) Air-popped popcorn.
c) Hot chocolate.
d) Raw vegetables.

4. A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum?
a) Maintain bed rest with bathroom privileges.
b) Advance the tube 2 to 4 inches at specified times.
c) Avoid frequent mouth care.
d) Provide ice chips for the client to suck.

5. A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock?
a) Tachycardia.
b) Dry, flushed skin.
c) Increased urine output.
d) Loss of consciousness.

6. After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
a) Peritonitis.
b) Thrombophlebitis.
c) Ascites.
d) Inguinal hernia

7. A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:
a) the client requires an antiviral agent.
b) enteric precautions must be continued.
c) enteric precautions can be discontinued.
d) the client's infection may be caused by droplet transmission

8. The comatose victim of the car accident is to have a gastric lavage. Which of the following positions would be most appropriate for the client during this procedure?
a) Lateral.
b) Supine.
c) Trendelenburg's.
d) Lithotomy.

 9. A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:
a) Absence of nausea and vomiting.
b) Passage of mucus from the rectum.
c) Passage of flatus and feces from the colostomy.
d) Absence of stomach drainage for 24 hours.

10. A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
a) Straw-colored urine
b) Reduced hematocrit
c) Clay-colored stools
d) Elevated urobilinogen in the urine

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Nclex Rn Examnination Practice Gastrointestinal Disorders Questions

 1.A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock?
a) Tachycardia.
b) Dry, flushed skin.
c) Increased urine output.
d) Loss of consciousness

2.A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum?
a) Maintain bed rest with bathroom privileges.
b) Advance the tube 2 to 4 inches at specified times.
c) Avoid frequent mouth care.
d) Provide ice chips for the client to suck

3.A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?
a) Lean beef.
b) Air-popped popcorn.
c) Hot chocolate.
d) Raw vegetables

4.Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?

a) The client will be maintained on bed rest for several days.

b) Ambulation is restricted by the presence of drainage tubes.

c) The operative incision is near the diaphragm.

d) The presence of a nasogastric tube inhibits deep breathing

5.A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid?

a) "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity."

b) "The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration."

c) "The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach."

d) "The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption."

6.Which of the following client statements indicates that the client with hepatitis B understands discharge teaching?

a) "I will not drink alcohol for at least 1 year."

b) "I must avoid sexual intercourse."

c) "I should be able to resume normal activity in a week or two.

d) "Because hepatitis B is a chronic disease, I know I will always be jaundiced."

7.Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids?

a) Decrease fiber in the diet.

b) Take laxatives to promote bowel movements.

c) Use warm sitz baths.

d) Decrease physical activity

8.A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?

a) "I'll increase my intake of protein during exacerbations."

b) "I should increase my intake of fresh fruits and vegetables during remissions."

c) "I'll snack on nuts, olives, and popcorn during flare-ups."

d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."

9.Which of the following laboratory findings are expected when a client has diverticulitis?

a) Elevated red blood cell count.

b) Decreased platelet count.

c) Elevated white blood cell count.

d) Elevated serum blood urea nitrogen concentration.

10.A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?

a) Autonomy

b) Fidelity

c) Nonmaleficence

d) Veracity

11.Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following?

a) Nausea.

b) Dizziness.

c) Abdominal spasms.

d) Abdominal distention.

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Answer & Rational Ventricular Tachycardia and Cardiac Disorders Nclex

Answer & Rational Ventricular Tachycardia and Cardiac Disorders Nclex
1.Answer: b .
Rationale:Raynaud ’s disease responds favorably to eliminating caffeine from the diet and cessation of smoking. Medications may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms still could occur with the use of air conditioning and during periods of cooler weather
2.Answer:a .
Rationale:The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger ’s disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component
3.Answer:b .
Rationale:Hypersensitivity or a sensation of “pins and needles ”in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported.

4.Answer:c .
Rationale:Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
5.Answer:b .
Rationale:In the first several hours after insertion of a permanent or a temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client ’s activities of the arm on the side of the insertion site.
6.Answer: c .
Rationale:An automatic internal cardioverter-defibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes related to ventricular tachycardia.

7. Answer: b .
Rationale:The nurse or rescuer puts two large adhesive patch electrodes on the client ’s chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds . The machine then indicates if defibrillation is necessary
8.Answer: a .
Rationale:After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation.
9.Answer:c .
Rationale:The client may be defibrillated up to three times in succession . The energy levels used are 200 , 300 , and 360 J for the first , second , and third attempts , respectively .
10.Answer: c .
Rationale:Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
11.Answer:c .
Rationale:Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
12.Answer: a .
Rationale:Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm . Options b , c , and d are incorrect descriptions of this procedure .
13.Answer:a .
Rationale:Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombi formation
14.Answer: C .
Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
15.Answer: d .
Rationale:Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds . Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented . Options a, b , and c will not assist in terminating the dysrhythmia.
16.Answer: c .
Rationale:First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is contraindicated.

17.Answer:a .
Rationale:Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
18.Answer:C .
Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second) , and typically a rate between 140 and 180 impulses/min . The rhythm is regular. Level of
19.Answer:b .
Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are higher than 100 beats/min .
20.Answer: c .
Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 and 4 will not help in tolerating ambulation . Removal of telemetry equipment is contraindicated unless prescribed.
21.Answer:b .
Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or glomerulonephritis.
22.Answer:b .
Rationale:Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium .
23.Answer:b .
Rationale:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
24.Answer:a.
Rationale: Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart.

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Chronic Obstructive Pulmonary Disease (COPD) Nclex RN Practice Questions

Chronic Obstructive Pulmonary Disease (COPD) Nclex RN Practice Questions

01.The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan?
a. Clubbing of nail beds
b. Hypertension
c. Peripheral edema
d. Increased appetite

02. Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD?
a. Increased anteroposterior chest diameter
b. Underdeveloped neck muscles
c. Collapsed neck veins
d. Increased chest excursions with respiration


03. A client with COPD reports steady weight loss and being “too tired from just breathing to eat.” Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client?
a. Altered nutrition: Less than body requirements related to fatigue.
b. Activity intolerance related to dyspnea.
c. Weight loss related to COPD.
d. Ineffective breathing pattern related to alveolar hypoventilation.

04. An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she develops a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?
a. It is likely that the client is developing a secondary bacterial pneumonia.
b. The assessment findings are consistent with influenza and are to be expected.
c. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions.
d. The client has not been taking her decongestants and bronchodilators as prescribed.

05. Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:
a. Maintain a fluid intake of 800 ml every 24 hours.
b. Experience chills only once a day
c. Cough productively without chest discomfort.
d. Experience less nasal obstruction and discharge.

06. The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack?
a. Decreased PaCO2, increased PaO2, and decreased pH.
b. Increased PaCO2, decreased PaO2, and decreased pH.
c. Increased PaCO2, increased PaO2, and increased pH.
d. Decreased PaCO2, decreased PaO2, and increased pH.


07. A client is prescribed metaproterenol (Alupent) via a metered dose inhaler (MDI), two puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol?
a. Irregular heartbeat
b. Constipation
c. Pedal edema
d. Decreased heart rate.

08. A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2 86%. Considering these results, the first intervention is to:
a. Begin mechanical ventilation
b. Place the client on oxygen
c. Give the client sodium bicarbonate
d. Monitor for pulmonary embolism.

09. If a client continues to hypoventilate, the nurse will continually assess for a complication of:
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

10. A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia?
a. Fluid volume deficit related to blood loss.
b. Impaired tissue perfusion related to thrombosis
c. Activity intolerance related to dyspnea
d. Risk for infection related to suppressed immune response.

Answer and Rational
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Ventricular Tachycardia and Cardiac Disorders Nclex Practice Questions

  Ventricular Tachycardia and Cardiac Disorders Nclex Practice Questions
1.A nurse has given instructions to the client with Raynaud ’s disease about self-management of the disease process. The nurse determines that the client needs further reinforcement of teaching if the client states which of the following?
a . “Smoking cessation is important. ”
b . “Moving to a warmer climate is needed. ”
c . “Sources of caffeine should be eliminated from the diet. ”
d . “Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."

2.A 24-year- old man seeks medical attention for complaints of claudication in the arch of the foot . A nurse also notes superficial thrombophlebitis of the lower leg. For which risk factor should the nurse assess based on these clinical findings?

a . Smoking history
b . Recent exposure to allergens
c . History of recent insect bites
d . Familial tendency toward peripheral vascular disease

3.A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of “pins and needles ”in the affected leg. Which of the following would be an appropriate action by the nurse based on evaluation of the client ’s comment?
a . Instruct the client to apply warm packs.
b . Report the complaint to the physician.
c . Reassure the client that this is only temporary.
d . Advise the client to take acetaminophen (Tylenol) until it is gone.

4.A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of which of the following?
a . Pneumonia
b . Pulmonary edema
c . Pulmonary embolism
d . Myocardial infarction


5.A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which of the following activities will assist with preventing dislodgement of the pacing catheter?
a . Limiting movement and abduction of the left arm
b . Limiting movement and abduction of the right arm
c . Assisting the client to get out of bed and ambulate with a walker
d . Having the physical therapist do active range-of-motion exercises to the right arm 


6.A nurse employed in a cardiac unit determines that which of the following clients is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)?
a . A client with syncopal episodes related to ventricular tachycardia
b . A client with ventricular dysrhythmias despite medication therapy
c . A client with an episode of cardiac arrest related to myocardial infarction
d . A client with three episodes of cardiac arrest unrelated to myocardial infarction

7.A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client ’s cardiac rhythm?
a. Hold the defibrillator paddles firmly against the chest.
b . Apply adhesive patch electrodes to the chest and move away from the client.
c . Apply standard electrocardiographic monitoring leads to the client and observe the rhythm.
d . Connect standard electrocardiographic electrodes to a transtelephonic monitoring device.

8.A nurse would evaluate that defibrillation of a client was most successful if which of the following observations was made?
 a . Arousable , sinus rhythm , BP 116/72 mm Hg
b . Arousable , marked bradycardia , BP 86/54 mm Hg
c . Nonarousable , supraventricular tachycardia , BP 122/60 mm Hg
d . Nonarousable , sinus rhythm , BP 88/60 mm Hg


9.A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the machine should be set at which of the following energy levels (in joules, J) for the first delivery?
a . 50 J
b . 100 J
c . 200 J
d . 360 J

10.A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client ’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How would the nurse correctly interpret this rhythm?
 a . Asystole
b . Atrial fibrillation
c . Ventricular fibrillation
d . Ventricular tachycardia

11.A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client ’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How would the nurse correctly interpret this rhythm?
a . Asystole
b . Atrial fibrillation
c . Ventricular fibrillation
d . Ventricular tachycardia

12.A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid sinus massage. Which of the following would be reflective of a correct explanation provided by the nurse?
 a . The vagus nerve slows the heart rate.
 b . The diaphragmatic nerve slows the heart rate.
c . The diaphragmatic nerve overdrives the rhythm.
d . The vagus nerve increases the heart rate, overdriving the rhythm.

13.A nurse is watching the cardiac monitor, and a client ’s rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client ’s heart rhythm?
a. Atrial fibrillation
b . Sinus tachycardia
c . Ventricular fibrillation
d . Ventricular tachycardia

14.A client has developed atrial fibrillation , with a ventricular rate of 150 beats/min . The nurse should assess the client for which associated signs or symptoms?
a . Flat neck veins
b . Nausea and vomiting
c . Hypotension and dizziness
d . Hypertension and headache 

15.A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia?
a . Lie down flat in bed.
b . Remove any metal jewelry.
c . Breathe deeply, regularly, and easily.
d . Inhale deeply and cough forcefully every 1 to 3 seconds .


16.A nurse is viewing the cardiac monitor in a client ’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?
a . Immediately defibrillate.
b . Prepare for pacemaker insertion.
c . Administer amiodarone (Cordarone) intravenously.
d . Administer epinephrine (Adrenalin) intravenously. 


17.most concerned about with this dysrhythmia?
a . It can develop into ventricular fibrillation at any time.
b . It is almost impossible to convert to a normal rhythm.
c . It is uncomfortable for the client, giving a sense of impending doom.
d . It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.


18.A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves , the QRS complexes are wide , and the ventricular rate is regular but over 100 beats/min . The nurse determines that the client is experiencing which of the following dysrhythmias? 
a . Sinus tachycardia
b . Ventricular fibrillation
c . Ventricular tachycardia
d . Premature ventricular contractions


19.A client ’s electrocardiogram strip shows atrial and ventricular rates of 110 beats/min . The PR interval is 0.14 second , the QRS complex measures 0.08 second , and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
a. Sinus arrhythmia
b . Sinus tachycardia
c . Sinus bradycardia
d . Normal sinus rhythm


20.A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?
a . Remove telemetry equipment.
b . Provide the client with a walker.
c . Premedicate the client with an analgesic.
d . Encourage the client to cough and deep breathe.

21.A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours . The client received a single bolus of 500 mL of intravenous fluid . Urine output for the subsequent hour was 25 mL . Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL . Based on these findings , the nurse would anticipate that the client is at risk for which of the following?
a . Hypovolemia
b . Acute renal failure
c . Glomerulonephritis
d . Urinary tract infection

22.A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client?
a. Bradycardia
b . Ventricular dysrhythmias
c . Rising diastolic blood pressure
d . Falling central venous pressure

23.A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client ’s breath sounds?
 a . Stridor
b . Crackles
c . Scattered rhonchi
d . Diminished breath sounds

24.A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician ’s office. The nurse would plan on having which of the following medications readily available for use?
a . Digoxin (Lanoxin)
b . Verapamil (Calan)
c . Propranolol (Inderal)
d . Diltiazem (Cardizem)

Answers & Rationals

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Answer and Rational Respiratory Disorders Nclex RN Exams

 Answer and Rational Respiratory Disorders Nclex RN Exams
01.Answer C
Rational: Nuchal rigidity is a sign/symptom of meningitis,which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges.and Answer a,b,and d.Muscle weakness is a sign/symptom of myalgia,but it is not a life-threatening complication of sinusitis.Purulent sputum would be a sign/symptom of a lung infection, but it is not a life threatening complication of  inusitis.Intermittent loss of muscle control can be a symptom of multiple sclerosis, but it would not be a life-threatening complication of sinusitis.

02.Answer a
Rational: Alternative therapies are therapies that are not accepted medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system’s functions.and Answer b,c,and d.Bed rest is accepted standard advice for a client with a cold.Humidifying the air helps to relieve congestion and is a standard practice.Decongestant therapy is standard therapy for a cold.

03.Answer c
Rational: To determine the antibiotic that will effectively treat an infection, specimens for culture are taken prior to beginning the medication. Administering antibiotics prior to cultures may make it impossible to determine the actual agent causing the pneumonia.answer a,b and d.Broad-spectrum IV antibiotics are priority, but before antibiotics are administered, it is important to obtain culture specimens to determine the correct antibiotic for the client’s infection.Clients are placed on oral medications only after several days of IVPB therapy.Meal trays are not priority over cultures.Admission weights are important to determine appropriate dosing of medication, but they are not priority over sputum collection.

04.Answer b
Rational:Turning the client to the side allows for the food to be coughed up and come out of the mouth, rather than be aspirated into the lungs.and Answer a,c,and d The nares are the opening of the nostrils.Suctioning, if done, would be of the posterior pharynx.Placing the client in the Trendelenburg position would increase the risk of aspiration.An immediate action is needed to protect the client.

05.Answer b
Rational: The nurse should decrease the oxygen rate.Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the oxygen level increases,the drive to breathe may be eliminated.Careful monitoring is important to prevent complications.and answer a,c,d .A large amount of thick sputum is a common symptom of COPD. There is no cause for immediate intervention.It is common for clients with COPD to use accessory muscles when inhaling. These clients tend to lean forward.In clients with COPD, there is a characteristic barrel chest from chronic hyperinflation, and dyspnea is common.

06.Answer c
Rational:Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD.and answer a,b,d.Clubbing fingers is the result of chronic hypoxemia,which would be expected with chronic COPD but not with recently diagnosed COPD.These clients have frequent respiratory infections.These clients have a productive cough, not a nonproductive cough.

07.Answer b
Rational: Clients with intermittent asthma will have exacerbations that are treated with rescue inhalers. Therefore, the nurse should teach the client about rescue inhalers.and answer a,c,d.Daily inhaled steroids are used for mild, moderate,or severe persistent asthma, not for intermittent asthma.Systemic steroids are used frequently by clients with severe persistent asthma, not with mild intermittent asthma.Leukotriene agonists are prescribed for clients diagnosed with mild persistent asthma.

08.Answer b
Rational:The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath.and answer a,c,d.This is a sign of a deep vein thrombosis, which is a precursor to a PE, but it is not a sign of a pulmonary embolism.These are signs of a myocardial infarction.These could be signs of pneumonia or other pulmonary complications, but not specifically a PE.

09.Answer c
Rational:Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.and answer a,b,d .Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is appropriate, but it is not the first intervention.Making sure alarms are functioning properly is appropriate, but checking a machine is not priority.Monitoring lab results is an appropriate intervention for the client on a ventilator, but monitoring laboratory data is not the priority intervention.

10.Answer c
Rational: Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilation.A urine output of 30 mL/hr indicates the kidneys are functioning properly.This indicates that the client is being adequately oxygenated.An increased heart rate does not indicate a
complication; this could result from numerous reasons that are not specifically because of the ventilator.

11.Answer a
Rational: When peak airway pressure is increased,the nurse should implement the intervention that is less invasive for the client.This alarm goes off with a plugged airway,“bucking” in the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.and answer b,c,d.The alarm may indicate that the client needs suctioning, but the nurse should always do the least invasive procedure when troubleshooting a ventilator alarm.The lip line on the ET tube determines how far the ET tube is in the trachea. It should always stay the same number, but it would not have anything to do with the ventilator alarms.This may be needed, but the nurse should not sedate the client unless absolutely necessary.

12.Answer b
Rational: Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation.

13.Answer c
Rational: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

14.Answer a
Rational.Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client’s status, but the priority in this case is alleviating the symptoms.

15.Answer b
Rational: Tubercle bacilli are spread by airborne droplet nuclei. Droplet nuclei are the residue of evaporated droplets containing the bacilli, which remain suspended and are circulated in the air. Dust particles and water do not spread tubercle bacilli.Tuberculosis is not spread by eating utensils, dishes,or other fomites.

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Respiratory Disorders Nclex RN Exams Practice Questions

Respiratory Disorders Nclex RN Exams Practice Questions
 01. The client has been diagnosed with chronic sinusitis. Which signs and symptoms would alert the nurse to a potentially life-threatening complication?
a. Muscle weakness.
b. Purulent sputum.
c. Nuchal rigidity.
d. Intermittent loss of muscle control.

02. The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy?
a. Vitamin C, 2000 mg daily.
b. Strict bed rest.
c. Humidification of the air.
d. Decongestant therapy.

03. 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 oral antibiotic 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 nursing assistant weigh the client.

04. While feeding the client diagnosed with aspiration pneumonia, the client becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention would the nurse implement first?
a. Suction the client’s nares.
b. Turn the client to the side.
c. Place the client in the Trendelenburg position.
d. Notify the health-care provider.

05. When assessing the client with the diagnosis of COPD, which data would require the nurse to take immediate action?
a. Large amounts of thick white sputum.
b. Oxygen flow meter set on eight (8) liters.
c. Use of accessory muscles during inspiration.
d. Presence of a barrel chest and dyspnea.

06. When assessing the client recently diagnosed with COPD, which sign and symptom should the nurse expect?
a. Clubbing of the client’s fingers.
b. Infrequent respiratory infections.
c. Chronic sputum production.
d. Nonproductive hacking cough.

07. The client is diagnosed with mild intermittent asthma. Which medication should the nurse discuss with the client?
a. Daily inhaled corticosteroids.
b. Use of a “rescue inhaler.”
c. Use of systemic steroids.
d. Leukotriene agonists.

08. Which assessment data would support that the client has experienced a pulmonary embolus?
a. Calf pain with dorsiflexion of the foot.
b. Sudden onset of chest pain and dyspnea.
c. Left-sided chest pain and diaphoresis.
d. Bilateral crackles and low-grade fever.

09. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
a. Confirm that the ventilator settings are correct.
b. Verify that the ventilator alarms are functioning properly.
c. Assess the respiratory status and pulse oximeter reading.
d. Monitor the client’s arterial blood gas results.

10. Which assessment data would indicate the client diagnosed with ARDS has experienced a complication secondary to the ventilator?
a. The client’s urine output is 100 mL in two (2) hours.
b. The pulse oximeter reading is greater than 95%.
c. The client has asymmetrical chest expansion.
d. The telemetry reading shows sinus tachycardia.

11. The client diagnosed with ARDS is on a ventilator and the high alarm indicates that there is an increase in the peak airway pressure. Which intervention should the nurse implement first?
a. Check the tubing for any kinks.
b. Suction the airway for secretions.
c. Assess the lip line of the ET tube.
d. Sedate the client with a muscle relaxant.

12.The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:
a)Relief from spasms of the diaphragm.
b)Relaxation of smooth muscles in the bronchioles.
c)Efficient pulmonary circulation.
d)Stimulation of the medullary respiratory center.

13.A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?
a)The client sees his physician for a check-up yearly.
b)The client has never traveled outside of the country.
c)The client had a liver transplant 2 years ago.
d)The client works in a health care insurance office.


14. A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort.What should the nurse do first?
a. Elevate the head of the bed 30 to 45 degrees.
b. Encourage the client to cough and deep breathe.
c. Auscultate the lungs to detect abnormal breath sounds.
d. Contact the physician.

15. The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:
a. Dust particles.
b. Droplet nuclei.
c. Water.
d. Eating utensils.

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