NCLEX Daily Ten Question Practical Exercise 9

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6. The nurse is evaluating a 63-year-old female patient who has been admitted with worsening heart failure. During the physical examination, the nurse uses a stethoscope to listen to the patient’s lung fields. The patient presents with shortness of breath, a cough that worsens when lying down, and fatigue. Which type of breath sounds is the nurse most likely to auscultate that are typically associated with heart failure?

A. Tracheal

B. Fine crackles

C. Coarse crackles

D. Friction rubs

E. Wheezes

F. Stridor

G. Pleural knock

Correct Answer: B

Answer Explanation:

This choice is the most consistent with fluid accumulation in the air spaces of the lungs, a common complication in patients with heart failure. Fine crackles are created by the opening of small airways and alveoli that are compromised by fluid, which is often present in heart failure due to the heart’s reduced ability to pump effectively.

7. A nurse is attending to a 35-year-old patient with a history of asthma who presents to the emergency department in the midst of an acute asthma exacerbation. The patient, who was initially wheezing loudly, suddenly has no audible wheezing and the nurse cannot auscultate breath sounds. The patient appears anxious and is using accessory muscles to breathe. Considering the change in respiratory status, what is the most likely explanation for the absence of wheezing?

A. The asthma attack has resolved.

B. The airways are so constricted that air cannot pass through.

C. The inflammation within the airways has subsided.

D. Fine crackles have replaced the wheezes due to fluid in the airways.

E. The patient is holding their breath subconsciously due to anxiety.

F. A foreign body has obstructed the airway passage.

Correct Answer: B

Answer Explanation:

This indicates that the airway constriction has worsened to a critical level, often resulting in a silent chest, which is a sign of a severe and life-threatening asthma attack. Immediate intervention is necessary to open the airways and restore adequate ventilation.

8. A nurse is caring for a 22-year-old individual with a known diagnosis of epilepsy. During the nurse’s shift, the patient begins to have a tonic-clonic seizure. During the active phase of the seizure, which of the following actions should the nurse take? Select all that apply.

A. Place the patient on their back, remove dangerous objects from the immediate vicinity, and insert a padded tongue depressor.

B. Place the patient in a lateral position (on their side), remove any hazardous objects nearby, and prepare to use a bite block if needed.

C. Position the patient supine (on their back), clear the area of any items that might cause injury, and restrain their limbs gently.

D. Turn the patient to a side-lying position, ensure the environment is safe from potential hazards, and use a pillow or a hand to protect the head.

E. Keep the patient in a prone position, secure the perimeter for safety, and monitor their respiratory status closely.

F. Roll the patient onto their side to prevent aspiration, remove objects that could cause harm, and observe for cessation of seizure activity.

Correct Answer: B D F

Answer Explanation:

During a seizure, it is important to prevent injury to the patient. Placing the patient on their side can help maintain an open airway and allow any oral secretions or vomitus to drain, preventing aspiration. Removing dangerous objects helps to minimize the risk of injury. While a bite block may be used in some situations to prevent the patient from biting their tongue, it is not recommended to insert anything into the mouth of someone who is actively seizing due to the risk of injury or aspiration. Protecting the head is also crucial to prevent trauma during convulsive movements.

9. After insertion of a chest tube for a pneumothorax, a client becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. Nurse Amanda suspects a tension pneumothorax has occurred. What cause of tension pneumothorax should the nurse check for?

A. Infection of the lung

B. Kinked or obstructed chest tube

C. Excessive water in the water-seal chamber

D. Excessive chest tube drainage

Correct Answer: B

Answer Explanation:

Kinking and blockage of the chest tube is a common cause of a tension pneumothorax.

Option A: Infection of the lung won’t cause a tension pneumothorax. A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function.
Option C: Excessive water won’t affect the chest tube drainage. The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity or mediastinum on inhalation.
Option D: An excessive chest tube drainage cannot cause tension pneumothorax. Chest tubes drain blood, fluid, or air from around the lungs, heart, or esophagus. The tube around the lung is placed between the ribs and into the space between the inner lining and the outer lining of the chest cavity.

10. The nurse is providing lunch to a 68-year-old male patient with a history of stroke which has affected his swallowing reflex. As the patient begins to eat, he suddenly starts choking on a piece of food but is coughing loudly and forcefully. Observing this, what should the nurse do?

A. Assist the patient to stand up and perform the abdominal thrust maneuver immediately.

B. Lay the patient down and prepare to perform back blows and chest thrusts.

C. Exit the room quickly to summon for additional help from the healthcare team.

D. Stay with the patient, encourage him to keep coughing, and monitor him closely.

E. Provide a drink of water to help the patient swallow the obstructing food.

Correct Answer: D

Answer Explanation:

When an individual is choking but still able to cough forcefully, it indicates that the airway is not completely blocked and air is still passing through. The coughing reflex is the most effective way to expel an obstruction from the airway. Therefore, the nurse should closely observe the client and encourage them to continue coughing. Performing abdominal thrusts or back blows when the individual is still able to cough may worsen the situation or cause unnecessary harm.

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