NCLEX-PN Test #19 3

Question 1

A client on a mechanical ventilator suddenly develops increasing peak airway pressures, decreased breath sounds on the left, tracheal deviation to the right, and hypotension. What complication does the nurse suspect?

Accepted Answer

Left-sided tension pneumothorax

Answer

Tension pneumothorax presents with: tracheal deviation AWAY from the affected side (to the right = left-sided tension pneumo), absent breath sounds on the affected side, hypotension (obstructive shock), rising peak airway pressures on the ventilator, and cyanosis. It requires immediate needle decompression (2nd intercostal space, midclavicular line) — it is rapidly fatal.

Question 2

The nurse is caring for a client with adult respiratory distress syndrome (ARDS). Which ventilator strategy is the standard of care?

Accepted Answer

Lung-protective ventilation with low tidal volume (6 mL/kg of ideal body weight) and PEEP

Answer

ARDSnet lung-protective ventilation uses low tidal volumes (6 mL/kg IBW) to prevent ventilator-induced lung injury (volutrauma, barotrauma), PEEP (positive end-expiratory pressure) to recruit collapsed alveoli, and titrating FiO₂ to maintain SpO₂ 88–95%. High tidal volumes worsen ARDS by overdistending injured lung units.

Question 3

A client is being weaned from mechanical ventilation and extubated. Within 30 minutes, the client develops inspiratory stridor. What does this indicate?

Accepted Answer

Post-extubation laryngeal edema causing upper airway obstruction

Answer

Post-extubation stridor is inspiratory high-pitched sound caused by laryngeal or subglottic edema, which can progress to complete airway obstruction. It is an emergency: notify the provider immediately, administer racemic epinephrine nebulizer and/or IV dexamethasone as ordered, apply supplemental oxygen, and prepare for possible re-intubation.

Question 4

A client with a pulmonary embolism has been started on a heparin infusion. The nurse notes the aPTT is 28 seconds (sub-therapeutic). What is the appropriate action?

Accepted Answer

Notify the provider — the heparin dose likely needs to be increased per protocol

Answer

Therapeutic aPTT for heparin therapy is 60–100 seconds (1.5–2.5× normal). An aPTT of 28 seconds is sub-therapeutic, meaning the client is not adequately anticoagulated and remains at risk for further clot extension. The provider must be notified to increase the heparin dose per protocol or weight-based heparin nomogram.

Question 5

A client with severe community-acquired pneumonia has a PaO₂/FiO₂ ratio of 150. What does this value indicate?

Accepted Answer

Moderate to severe ARDS — meets criteria for ARDS diagnosis

Answer

The P/F ratio (PaO₂/FiO₂) categorizes ARDS severity: Mild ARDS = 200–300 (with PEEP ≥5 cmH₂O); Moderate ARDS = 100–200; Severe ARDS = < 100. A P/F ratio of 150 indicates moderate ARDS. Normal P/F is > 400. This client requires lung-protective mechanical ventilation. (Berlin Definition 2012).

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #19 3