NCLEX-PN Test #8 2 — Questions and Answers
Question 1: A client is admitted with status asthmaticus. After administering albuterol via nebulizer, the nurse reassesses and notes the client's SpO₂ is 90% and the wheezing has stopped. What does the absence of wheezing most likely indicate?
- The bronchospasm has completely resolved
- The client no longer needs intervention
- Severe airway obstruction with minimal air movement — a danger sign (Correct answer)
- Successful response to bronchodilator therapy
Correct answer: Severe airway obstruction with minimal air movement — a danger sign
In severe asthma, the "silent chest" (absence of wheeze) is an ominous sign indicating air movement is so reduced that no wheeze can be generated. This represents near-complete airway obstruction and impending respiratory failure. It is NOT a sign of improvement and requires immediate escalation of care.
Question 2: A client with pneumonia has a temperature of 39.2°C, productive cough with rust-colored sputum, and right lower lobe dullness on percussion. Which organism is most likely responsible?
- Mycoplasma pneumoniae (atypical)
- Streptococcus pneumoniae (Correct answer)
- Pseudomonas aeruginosa
- Legionella pneumophila
Correct answer: Streptococcus pneumoniae
Streptococcus pneumoniae (pneumococcal pneumonia) classically presents with abrupt onset fever, productive cough with rust-colored (blood-tinged) sputum, lobar consolidation (dullness on percussion), and pleuritic chest pain. Mycoplasma causes "walking pneumonia" with gradual onset; Legionella causes atypical pneumonia with GI symptoms.
Question 3: A client with a chest tube to water-seal drainage is ambulating in the hallway when the drainage tube accidentally disconnects from the collection system. What is the priority action?
- Clamp the chest tube immediately with two clamps
- Place the open end of the tube into a cup of sterile water (Correct answer)
- Reconnect the tubing as quickly as possible
- Call the provider and wait for orders
Correct answer: Place the open end of the tube into a cup of sterile water
If the chest tube disconnects from the collection system, the priority is to submerge the open end of the tube in a sterile water container (creating a water seal) to prevent air from entering the pleural space (tension pneumothorax). Reconnect as soon as possible. Clamping chest tubes is generally contraindicated as it can cause tension pneumothorax.
Question 4: The nurse is reviewing ABG results for a client on a ventilator: pH 7.28, PaCO₂ 58 mmHg, PaO₂ 78 mmHg, HCO₃ 24 mEq/L. How does the nurse interpret these results?
- Metabolic acidosis, uncompensated
- Respiratory alkalosis, compensated
- Respiratory acidosis, uncompensated (Correct answer)
- Metabolic alkalosis, compensated
Correct answer: Respiratory acidosis, uncompensated
pH < 7.35 = acidosis. PaCO₂ > 45 = respiratory cause (CO₂ is an acid). HCO₃ is normal (22–26) = no metabolic compensation has occurred. This is uncompensated respiratory acidosis, caused by CO₂ retention (hypoventilation). The ventilator rate or tidal volume may need adjustment.
Question 5: A client with cystic fibrosis is admitted with a pulmonary exacerbation. Which nursing intervention is most important in managing airway clearance?
- Encourage fluid restriction to reduce mucus production
- Perform chest physiotherapy (CPT) and postural drainage as ordered (Correct answer)
- Administer bronchodilators only at bedtime
- Keep the client at complete bed rest
Correct answer: Perform chest physiotherapy (CPT) and postural drainage as ordered
Airway clearance is the cornerstone of cystic fibrosis management. Chest physiotherapy with postural drainage mobilizes thick, tenacious secretions from the airways. Coupled with mucolytics (dornase alfa) and adequate hydration, CPT reduces exacerbation frequency and severity.
Question 6: A client requires suctioning. Which observation indicates the need for nasotracheal suctioning?
- SpO₂ of 97% on 2 L nasal cannula
- Coarse crackles that do not clear with coughing, RR 26/min (Correct answer)
- Productive cough with clear thin secretions
- Respiratory rate of 18 breaths per minute
Correct answer: Coarse crackles that do not clear with coughing, RR 26/min
Coarse crackles that do not clear with coughing, combined with an elevated respiratory rate, indicate retained secretions that the client cannot clear independently. Suctioning is indicated when secretions are present and the client cannot self-clear. SpO₂ desaturation may also trigger suctioning.
NCLEX-PN Test #8 2
A client is admitted with status asthmaticus.
After administering albuterol via nebulizer, the nurse reassesses and notes the client's SpO₂ is 90% and the wheezing has stopped.
What does the absence of wheezing most likely indicate?