NCLEX Exam Practice Question of the Week - 7/18/12

Elsevier NCLEX Exam Review

Question: A nurse assesses a client admitted to the hospital with rib fractures so as to identify the risk for potential complications. The nurse notes that the client has a history of emphysema.
After the assessment, the nurse ensures that which of the following interventions is documented in the plan of care? Select all that apply.

1. Collect sputum specimens at the hour of sleep.
2. Maintain the client in a position of comfort.
3. Offer medication to suppress the cough as needed.
4. Administer small, frequent meals with plenty of fluids.
5. Have the client cough and breathe deeply 20 minutes after pain medication is given.
6. Administer 4 to 6 liters of oxygen when the client’s pulse oximetry drops below 90%.

Answer: 2, 4, 5 

Rationale: If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client’s awakening. Productive cough is more likely to occur after the client has slept. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen (option 6) would halt the hypoxic drive and cause apnea. Options 2, 4, and 5 are appropriate interventions.

Priority Nursing Tip: Monitor the client with rib fractures for changes in respiratory rate or depth. Alterations in respiratory patterns can be caused by pain or a complication of the fractures.
Test-Taking Strategy: Focus on the data in the question and note that the client has emphysema. Recalling the pathophysiology associated with emphysema will assist in determining the correct options. Review the complications that can occur in the client with emphysema if you had
difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Adult Health/Respiratory
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., pp. 1583–1584). St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 631). St. Louis: Saunders.

This week’s NCLEX exam practice question came from:

Silvestri: Saunders Q&A Review for the NCLEX-RN Exam, 5th Edition, Test 6 (Comprehensive Test), pg 581, question 1251

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