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NCLEX-RN Exam Questions - Part 65
1. A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:
A) A left hemothorax
B) A right hemothorax
C) Intubation of the right mainstem bronchus
D) An inadequate mechanical ventilator
2. Which of the following blood gas parameters primarily reflects respiratory function?
A) PCO2
B) CO2 content of the blood
C) HCO3
D) Base excess
3. Endotracheal tube cuff pressure should never exceed:
A) 10 mm Hg
B) 20 mm Hg
C) 45 mm Hg
D) 60 mm Hg
4. The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
A) Ringer - s lactate
B) D5 in water
C) D5 with Ringer - s lactate
D) Normal saline
5. A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours postburn?
A) Fluid volume deficit secondary to alteration in skin integrity
B) Alteration in comfort secondary to alteration in skin integrity
C) Alteration in sensation secondary to third-degree burn
D) Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
A) A left hemothorax
B) A right hemothorax
C) Intubation of the right mainstem bronchus
D) An inadequate mechanical ventilator
2. Which of the following blood gas parameters primarily reflects respiratory function?
A) PCO2
B) CO2 content of the blood
C) HCO3
D) Base excess
3. Endotracheal tube cuff pressure should never exceed:
A) 10 mm Hg
B) 20 mm Hg
C) 45 mm Hg
D) 60 mm Hg
4. The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?
A) Ringer - s lactate
B) D5 in water
C) D5 with Ringer - s lactate
D) Normal saline
5. A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours postburn?
A) Fluid volume deficit secondary to alteration in skin integrity
B) Alteration in comfort secondary to alteration in skin integrity
C) Alteration in sensation secondary to third-degree burn
D) Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
1. Right Answer: C
Explanation: (A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.
2. Right Answer: A
Explanation: (A) The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function. (B) CO2 content of the blood is an indirect measure of respiratory function. (C) HCO3 is a measure of kidney function only and is important in acid-base balance. (D) Base excess represents the excess of HCO3 and is not reflective of respiratory function.
3. Right Answer: B
Explanation: (A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion.
4. Right Answer: D
Explanation: (A) Phenytoin will precipitate if mixed with Ringers lactate and should not be administered. (B, C) Phenytoin will precipitate if mixed with D5 in Ringers lactate and should not be administered. (D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.
5. Right Answer: D
Explanation: (A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the clients hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 4872 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this clients airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
Explanation: (A) Although a left hemothorax could cause diminished and distant breath sounds, it is irrelevant to this situation. (B) A right hemothorax will not cause diminished and distant breath sounds on the left side of the chest. (C) The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left. (D) An inadequate mechanical ventilator has no relationship to this situation.
2. Right Answer: A
Explanation: (A) The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function. (B) CO2 content of the blood is an indirect measure of respiratory function. (C) HCO3 is a measure of kidney function only and is important in acid-base balance. (D) Base excess represents the excess of HCO3 and is not reflective of respiratory function.
3. Right Answer: B
Explanation: (A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion.
4. Right Answer: D
Explanation: (A) Phenytoin will precipitate if mixed with Ringers lactate and should not be administered. (B, C) Phenytoin will precipitate if mixed with D5 in Ringers lactate and should not be administered. (D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.
5. Right Answer: D
Explanation: (A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the clients hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 4872 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this clients airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
80% DISCOUNT: NCLEX-RN PRACTICE EXAMS
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