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

A SpO2 of 88% is below the normal range (95–100%) and indicates hypoxemia. The nurse must notify the provider and apply supplemental oxygen per protocol or order. Delaying action or attributing the reading to probe error without clinical assessment is unsafe.

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

The reservoir bag on a non-rebreather mask should never fully deflate during inspiration. If it does, the flow rate is insufficient to meet the patient's inspiratory demand and the patient is breathing room air, defeating the purpose of the high-flow device. The flow rate should be increased immediately.

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

Correct tracheostomy suction technique involves inserting the catheter without suction until resistance is met (or to the recommended depth), then applying intermittent suction while withdrawing with a rotating motion. Each pass should not exceed 10–15 seconds to prevent hypoxia. The catheter should be rinsed between passes.

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

pH 7.31 = acidosis; elevated PaCO2 58 mmHg = respiratory cause (CO2 retention); HCO3 26 mEq/L is slightly elevated but within normal range, indicating early or minimal compensation. This is respiratory acidosis — consistent with COPD exacerbation and CO2 retention.

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

Stridor after bronchoscopy indicates laryngospasm or significant airway edema — a life-threatening complication requiring immediate intervention. While a sore throat and hoarseness are expected, stridor with respiratory distress demands emergency response including notification of the provider and preparation for airway management.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #20 1