NCLEX-PN Test #8 2

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?

Accepted Answer

Severe airway obstruction with minimal air movement — a danger sign

Answer

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?

Accepted Answer

Streptococcus pneumoniae

Answer

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?

Accepted Answer

Place the open end of the tube into a cup of sterile water

Answer

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?

Accepted Answer

Respiratory acidosis, uncompensated

Answer

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?

Accepted Answer

Perform chest physiotherapy (CPT) and postural drainage as ordered

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #8 2