which of the following may represent an upper airway obstruction

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. Which of the following may represent an upper airway obstruction?

A. Retractions
B. Elongated expiratory phase
C. Stridor
D. Expiratory wheezing

Correct answer: C

Rationale: Stridor is the sound produced by turbulent airflow through a partially obstructed upper airway. It is a classic sign of upper airway obstruction. While an elongated expiratory phase may indicate lower airway obstruction, stridor specifically points to an upper airway issue. Retractions are also often seen in upper airway obstruction due to the increased effort of breathing. Expiratory wheezing, on the other hand, is more indicative of lower airway conditions such as asthma or chronic obstructive pulmonary disease (COPD).

2. The healthcare provider is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope?

A. Often used to direct light into the sinuses
B. Used to examine the structures of the internal ear
C. Uses a short, broad speculum to help visualize the ear
D. Directs light into the ear canal and onto the tympanic membrane

Correct answer: D

Rationale: The otoscope is a tool used to examine the ear canal and tympanic membrane, which separates the external and middle ear. It is not intended to direct light into the sinuses or examine the internal structures of the ear. The otoscope typically uses a short, narrow speculum to aid in visualizing the ear canal and tympanic membrane, not a short, broad speculum as mentioned in choice C.

3. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

A. Vest restraints should be used because they are the least restrictive type.
B. Restraints should be used for 48 hours in non-psychiatric patients.
C. Restraints should be applied to prevent wandering behavior.
D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

4. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?

A. Inform the client that he may experience tingling sensations.
B. Connect the TENS unit before the client goes to bed for the night.
C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.

Correct answer: A

Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.

5. When would chest thrusts be performed in an emergency situation?

A. When performing CPR to initiate cardiovascular circulation.
B. When assessing responsiveness of an unconscious patient.
C. When assisting a pregnant woman who is choking.
D. None of the above examples indicate the need for chest thrusts.

Correct answer: C

Rationale: In the scenario of an emergency where a pregnant woman is choking, chest thrusts are performed to clear the airway obstruction. This technique is used instead of abdominal thrusts to avoid potential harm to the fetus. While chest thrusts are not as effective as abdominal thrusts in clearing obstructions, they are the preferred method in this specific situation. Choices A and B are incorrect as chest thrusts are not typically performed during CPR to initiate cardiovascular circulation or when assessing responsiveness of an unconscious patient. Choice D is incorrect as chest thrusts are indeed warranted when assisting a pregnant woman who is choking.