NCLEX-PN Test #20 1

Question 1

A patient's pulse oximetry reading is 88% on room air. What is the nurse's priority action?

Accepted Answer

Notify the physician and apply supplemental oxygen as ordered

Answer

Document the finding and recheck in 1 hour

Answer

Encourage the patient to breathe deeply and recheck in 15 minutes

Answer

Reposition the probe and assume the reading is inaccurate

Question 2

A nurse is caring for a patient receiving oxygen via a non-rebreather mask at 15 L/min. Which assessment finding requires immediate intervention?

Accepted Answer

Reservoir bag deflating completely on inspiration

Answer

SpO2 of 97%

Answer

Respiratory rate of 14 breaths per minute

Answer

Patient reports the mask feels tight

Question 3

A nurse is suctioning a patient with a tracheostomy. Which action reflects correct technique?

Accepted Answer

Insert the catheter until resistance is met, then apply suction while withdrawing with a rotating motion

Answer

Apply suction continuously while inserting the catheter

Answer

Suction for up to 45 seconds to ensure airway clearance

Answer

Use the same suction catheter for repeated passes without rinsing

Question 4

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?

Accepted Answer

Respiratory acidosis with normal metabolic response

Answer

Respiratory alkalosis with metabolic compensation

Answer

Metabolic acidosis with respiratory compensation

Answer

Normal ABG within acceptable limits

Question 5

A nurse is caring for a patient post-bronchoscopy. Which assessment finding should concern the nurse most immediately?

Accepted Answer

Stridor and increasing respiratory distress

Answer

Mild sore throat

Answer

Hoarse voice immediately after the procedure

Answer

Patient drowsy but arousable from sedation

Question 6

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?

Accepted Answer

Manually ventilate the patient with a bag-valve mask while assessing the cause

Answer

Silence the alarm and continue monitoring

Answer

Increase the tidal volume setting

Answer

Turn off the ventilator and contact respiratory therapy