NursingLink

News >> Browse Articles >> Nurse Features

Answers to the NCLEX Quiz Part II

1. Situation – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessive secretions in the airway. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Mario does percussion would be:

Client lying on his back then flat on his abdomen on Trendelenburg position
Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen- Correct answer!
Client lying flat on his back and then flat on his abdomen
Client lying on his right then left side on Trendelenburg position

2. When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:

Color, amount and consistency of sputum
Character of breath sounds and respiratory rate before and after procedure
Amount of fluid intake of client before and after the procedure- Correct answer!
Significant changes in vital signs

3. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:

Amount of food and fluid taken during the last meal before treatment
Respiratory rate, breath sounds and location of congestion
Teaching the client’s relatives to perform the procedure- Correct answer!
Doctor’s order regarding position restrictions and client’s tolerance for lying flat

4. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?

Respiratory rate of 16 to 20 per minute
Client can tolerate sitting and lying positions- Correct answer!
Client has no signs of infection
Time of last food and fluid intake of the client

5. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:

Percussion uses only one hand while vibration uses both hands
Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle- Correct answer!
In both percussion and vibration the hands are on top of each other and hand action is in tune with client’s breath rhythm
Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air