NCLEX-PN Test #8 1

Question 1

A client with COPD is admitted with acute exacerbation. The nurse prepares to administer supplemental oxygen. Which oxygen delivery method and flow rate is most appropriate for this client?

Accepted Answer

Nasal cannula at 1–2 L/min

Answer

Clients with COPD may rely on hypoxic drive to breathe. High-flow oxygen can eliminate this drive and cause respiratory depression. Low-flow oxygen via nasal cannula at 1–2 L/min is appropriate to maintain SpO2 at 88–92%. A Venturi mask is also acceptable for precise FiO2 delivery, but the standard starting approach is low-flow nasal cannula.

Question 2

A nurse is suctioning a client's tracheostomy. During suctioning, the client's SpO2 drops from 97% to 84%. Which action should the nurse take first?

Accepted Answer

Remove the suction catheter and apply 100% oxygen

Answer

A significant drop in SpO2 during tracheal suctioning indicates hypoxia. The nurse must immediately remove the suction catheter, apply 100% oxygen, and allow the client to recover before attempting suctioning again. Suctioning should never be applied for more than 10–15 seconds and should be preceded and followed by oxygenation.

Question 3

A nurse is performing auscultation on a client admitted with pneumonia. Crackles (rales) are heard in the right lower lobe. Which finding would the nurse most likely also observe?

Accepted Answer

Tachypnea and decreased breath sounds in the affected lobe

Answer

Pneumonia causes consolidation of the affected lobe, leading to decreased or absent breath sounds in the area, along with crackles from fluid in the alveoli. Tachypnea is a compensatory response. Barrel chest and prolonged expiration are COPD findings; wheezing suggests bronchospasm; stridor indicates upper airway obstruction.

Question 4

A postoperative client refuses to use the incentive spirometer, stating, 'It hurts too much to breathe deeply.' What is the nurse's best response?

Accepted Answer

Offer pain medication 30 minutes before incentive spirometry and splint the incision with a pillow

Answer

Postoperative pain is a barrier to deep breathing, which increases the risk of atelectasis and pneumonia. The most effective approach is to premedicate the client for pain (peaking before therapy) and teach splinting (supporting the incision with a pillow or folded blanket) to reduce discomfort during deep breathing exercises.

Question 5

A nurse is caring for a client on mechanical ventilation. The high-pressure alarm is sounding. Which condition is least likely to cause this alarm?

Accepted Answer

A disconnection in the ventilator circuit

Answer

A high-pressure alarm indicates increased resistance in the airway or circuit (e.g., secretions, biting, bronchospasm, coughing). A circuit disconnection or leak would trigger a low-pressure alarm, not a high-pressure one. This is the least likely cause of a high-pressure alarm.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #8 1