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.