NCLEX Respiratory System

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? A. Weak, rapid pulse B. Decreased blood pressure C. Radiating anterior chest pain D. Crackles at bases of the lungs

D. Crackles at bases of the lungs

A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy? A. Bronchoscopy B. Pulse oximetry C. Pulmonary function studies D. Culture and sensitivity tests of sputum

D. Culture and sensitivity tests of sputum

A nurse is caring for a client who has a tracheostomy tube and is on a ventilator. What must the nurse ensure about the tracheostomy tube? A. Has an inner cannula B. Is changed every week C. Is cleansed once a day D. Has a low-pressure cuff

D. Has a low-pressure cuff

The respiratory status of a client with Guillain-Barré syndrome progressively deteriorates, and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How should the nurse manage the tracheostomy cuff? A. Deflate the cuff before starting each tube feeding B. Inflate the cuff for one hour before and after each feeding C. Deflate the cuff after the tube feeding has been completed D. Inflate the cuff before the feeding and for 30 minutes after each feeding

D. Inflate the cuff before the feeding and for 30 minutes after each feeding

What is the major factor a nurse considers when anticipating the method of oxygen administration to be prescribed by the healthcare provider for a client? A. Activity level B. Facial anatomy C. Mental capacity D. Pathologic condition

D. Pathologic condition

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? A. Hypocapnia B. Hyperkalemia C. Generalized anemia D. Respiratory acidosis

D. Respiratory acidosis

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? A. Pink B. Clear C. Green D. Yellow

A. Pink

The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? A. Class I B. Class II C. Class III D. Class IV

C. Class III

A client with oat-cell lung cancer is scheduled for a mediastinoscopy and biopsy. What should the nurse include in the client's education? A. Chest tubes will be in place after the procedure. B. The procedure will visualize the mainstem bronchus. C. Some pleural fluid will be removed during the procedure. D. The procedure is an endoscopic examination of lymph nodes.

D. The procedure is an endoscopic examination of lymph nodes.

Cystic fibrosis (CF) is a genetic disorder that causes the endocrine glands to work incorrectly.

False: Cystic fibrosis (CF) is a genetic disorder that causes the EXOCRINE (not endocrine) glands to work incorrectly.

A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? A. "Cover your cough with your forearm." B. "Dispose of used paper tissues in a paper bag." C. "Encourage your roommate to get the flu vaccine." D. "Move out of your apartment until you are over the cold."

A. "Cover your cough with your forearm."

The nurse assesses a client with emphysema. The nurse expects to find which sign of chronic obstructive pulmonary disease (COPD)? A. Increased breath sounds B. Atrophic accessory muscles C. Shortened expiratory phase of the respiratory cycle D. Chest with an increased anteroposterior (AP) diameter

D. Chest with an increased anteroposterior (AP) diameter

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? A. Aspirating gastric contents B. Getting an opioid overdose C. Experiencing an anaphylactic reaction D. Receiving multiple blood transfusions

A. Aspirating gastric contents

You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS? A. Improvement in lung sounds B. Development of a V/Q mismatch C. PaO2 increased from 59 mmHg to 82 mmHg D. PEEP needs to be titrated to 15 mmHg of water

A. Improvement in lung sounds C. PaO2 increased from 59 mmHg to 82 mmHg

The oxygen saturation value of an African client measured through a pulse oximeter is 93%. What does the nurse infer from this reading? A. The client has a normal SpO2 value. B. The oximeter is unable to detect desaturation levels. C. The client has an abnormal SpO2 value. D. The oximeter may not work with clients experiencing impaired blood flow.

A. The client has a normal SpO2 value.

After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion? A. Wheezing B. Rhonchi C. Pleural friction rub D. Low-pitched crackles

A. Wheezing

A nurse teaches a client with a nose fracture about routine care after rhinoplasty surgery. Which statement of the client indicates the need for further teaching? A. "I should not sniff upwards or blow my nose." B. "I should take aspirin if I experience bleeding." C. "I should move slowly and remain in the semi-Fowler's position whenever possible." D. "I should not cough forcefully or strain during bowel movements."

B. "I should take aspirin if I experience bleeding."

The X-ray report of a client indicates a reduction in the alveolar surface area. Which condition can be inferred from this finding? A. Acinus B. Atelectasis C. Hemoptysis D. Histoplasmosis

B. Atelectasis

The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. Which immediate action should the nurse take? A. Weigh the client B. Auscultate breath sounds C. Obtain arterial blood gases D. Turn the client on the right side

B. Auscultate breath sounds

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding? A. Respiratory stridor B. Subcutaneous emphysema C. Bilateral 2+ pitting edema D. Chest distention

B. Subcutaneous emphysema

A nurse is caring for a client who had an open abdominal cholecystectomy because of biliary colic. Which nursing action is most important during the postoperative period? A. Maintaining T-tube drainage B. Ensuring a pain-free experience C. Encouraging coughing and deep breathing D. Providing a heating pad for shoulder pain for 15 minutes hourly

C. Encouraging coughing and deep breathing

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly? A. Contains many small air bubbles B. Bubbles vigorously on inspiration C. Rises with inspiration and falls with expiration D. Remains at a consistent level during the respiratory cycle

C. Rises with inspiration and falls with expiration

Histoplasmosis is suspected in a client. Which risk factor is the nurse likely to find in the history? A. The client is a chain smoker. B. The client works in a cement factory. C. The client has a history of a minor hand fracture. D. The client has a history of travel to central parts of North America.

D. The client has a history of travel to central parts of North America.

A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs? A. Increased restlessness B. No secretions when client is suctioned C. PaO2 of 93 D. Skin warm and dry

A. Increased restlessness

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? A. Inhales deeply through the mouthpiece, relaxes, and then exhales. B. Inhales deeply, seals the lips around the mouthpiece, and exhales. C. Uses the incentive spirometer for 10 consecutive breaths per hour. D. Coughs several times before inhaling deeply through the mouthpiece.

A. Inhales deeply through the mouthpiece, relaxes, and then exhales.

A client with the diagnosis of osteogenic sarcoma has a metastasis to the lung. Which client statement about the concept of metastasis indicates that the nurse needs to follow up? A. "I'm upset to know that the tumor may metastasize to my bones." B. "I didn't realize that I could have a metastasis without having pain." C. "I can have metastases to other parts of my body besides the lung." D. "I need to talk with my doctor about the possibility of more metastases."

A. "I'm upset to know that the tumor may metastasize to my bones."

A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished? A. Assess the person's breathing. B. Offer the person sips of water. C. Cover the person with a warm blanket. D. Calculate the extent of the person's burns.

A. Assess the person's breathing.

A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph? A. Cavities caused by caseation B. Sensitized T cells C. Presence of acid-fast bacilli D. Microscopic primary infection

A. Cavities caused by caseation

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. A. Crackles B. Atelectasis C. Hypoxemia D. Severe dyspnea E. Increased pulmonary wedge pressure

A. Crackles B. Atelectasis C. Hypoxemia D. Severe dyspnea

The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? Select all that apply. A. Dry cough B. Chest pain C. Hemoptysis D. Shortness of breath E. Fever greater than 100.4° F (38° C)

A. Dry cough D. Shortness of breath E. Fever greater than 100.4° F (38° C)

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? A. Encouraging a fluid intake of 3 L daily B. Suctioning via the tracheostomy every hour C. Applying an occlusive dressing over the surgical site D. Using cotton balls to cleanse the stoma with peroxide

A. Encouraging a fluid intake of 3 L daily

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take? A. Instruct the client to splint the wound with a pillow when coughing. B. Place the client in the supine position and inspect the site of the incision. C. Assess the intensity of the pain and administer the prescribed analgesic. D. Call the healthcare provider immediately and then check for wound dehiscence.

A. Instruct the client to splint the wound with a pillow when coughing.

You're providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis? A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23 B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26 C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29 D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19

A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23

An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response? A. "Stay away from preschool and school-aged children." B. "Avoid putting your hands near your nose and mouth." C. "Wear a sweater under your coat when going outside in cold weather." D. "Take an aspirin when you think you may be coming down with a cold."

B. "Avoid putting your hands near your nose and mouth."

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning? Select all that apply. A. "Resonance indicates the presence of trapped air." B. "Dullness can be percussed over a consolidated lung." C. "Hyperresonance is characteristic of normal lung tissue." D. "Tympanic notes over the lung usually indicate a large pneumothorax." E. "Flatness percussed over the lung fields indicates massive pleural effusion."

B. "Dullness can be percussed over a consolidated lung." D. "Tympanic notes over the lung usually indicate a large pneumothorax." E. "Flatness percussed over the lung fields indicates massive pleural effusion."

The nurse is teaching a student nurse about the preventive measures to be taken to prevent injury in clients who are receiving anticoagulant therapy. Which statement indicates the need for further teaching? A. "I will handle the client gently and carefully." B. "I will assess intravenous sites at least every 6 hours for bleeding." C. "I will use a lift sheet when moving and positioning the client in bed." D. "I will use the smallest gauge needle when injections or venipunctures are necessary."

B. "I will assess intravenous sites at least every 6 hours for bleeding."

While a client with a fractured femur is being prepared for surgery, the client exhibits cyanosis, tachycardia, dyspnea, and restlessness. What should be the nurse's first action? A. Call the healthcare provider B. Administer oxygen by mask C. Place the client in a high-Fowler position D. Move the bed into a Trendelenburg position

B. Administer oxygen by mask

During chest assessment of a client with idiopathic pulmonary fibrosis, the nurse hears short, discontinuous, high-pitched sounds that sound like hair being rolled between the fingers just behind the ear in the bilateral lower lobes. Which respiratory disorders may also manifest these sounds as a pathophysiological sign? Select all that apply. A. Croup B. Atelectasis C. Cystic fibrosis D. Bronchospasm E. Pulmonary edema

B. Atelectasis E. Pulmonary edema

A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg

B. Blood pressure 70/45

A client is diagnosed with emphysema. What long-term problem should the nurse monitor in this client? A. Localized tissue necrosis B. Carbon dioxide retention C. Increased respiratory rate D. Saturated hemoglobin molecules

B. Carbon dioxide retention

In addition to Pneumocystis jiroveci, a client with acquired immunodeficiency syndrome (AIDS) also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, what is the most critical concern? A. Skin integrity B. Gas exchange C. Social isolation D. Nutritional status

B. Gas exchange

A nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula? A. Has an upper respiratory infection B. Has many visitors while sitting in a chair C. Has a nasogastric tube for gastric decompression D. Has dry oral mucous membranes from mouth breathing

B. Has many visitors while sitting in a chair

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. What is the priority nursing intervention? A. Turn the client onto the right side B. Notify the healthcare provider immediately C. Document the output as an expected finding D. Irrigate the drainage catheter to ensure patency

B. Notify the healthcare provider immediately

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? A. Supine B. Orthopneic C. Low-Fowler D. Semi-Fowler

B. Orthopneic

A nurse administers oxygen at 2 L/min via nasal cannula to a client with emphysema. Which clinical indicators should the nurse closely observe in the client? Select all that apply. A. Anxiety B. Oxygenation C. Drowsiness D. Mental confusion E. Increased respirations

B. Oxygenation C. Drowsiness D. Mental confusion

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? A. Postural drainage B. Turning and positioning C. Administration of an expectorant D. Percussion and vibration techniques

B. Turning and positioning

During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to? A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema

B. atelectasis

Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis.

C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.

The nurse reviews teaching with a client who has laryngeal cancer and is scheduled for a total laryngectomy and radical neck dissection. The nurse concludes that the teaching is effective when the client makes which statement about what he will be able to do after recovering from surgery? A. After surgery, I will still be able to blow my nose. B. After surgery, I will still be able to sip through a straw. C. After surgery, I will still be able to chew and swallow food. D. After surgery, I will still be able to smell and differentiate odors.

C. After surgery, I will still be able to chew and swallow food.

A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide? A. Take rapid, deep breaths B. Breathe with hands on the hips C. Expand the abdomen on inhalation D. Perform exercises leaning forward while in a sitting position

C. Expand the abdomen on inhalation

After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion? A. Excessive fluid intake B. Inadequate chest expansion C. Extension of cancerous lesions D. Irritation from the bronchoscopy

C. Extension of cancerous lesions

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? A. Administering oxygen B. Using an incentive spirometer C. Having the client breathe into a paper bag D. Administering an IV containing bicarbonate ions

C. Having the client breathe into a paper bag

A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client? A. Assess frequently for nasal drying. B. Keep the mask tight against the face. C. Monitor oxygen saturation levels when eating. D. Set the oxygen flow at the highest setting possible.

C. Monitor oxygen saturation levels when eating.

Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? A. PaO2-72, SpO2- 96 B. PaO2-60, SpO2- 90 C. PaO2-55, SpO2- 88 D. PaO2-40, SpO2- 75

C. PaO2-55, SpO2- 88

As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS: A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis

C. Sepsis D. Blood transfusion F. Pancreatitis

The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication? A. Clots in the tubing during the first postoperative day B. Bloody fluid in the drainage-collection chamber on the first postoperative day C. Subcutaneous emphysema on the second postoperative day D. Decreased bubbling in the water-seal chamber on the third postoperative day

C. Subcutaneous emphysema on the second postoperative day

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

C. The patient's PaO2 remains at 45 mmHg.

During data collection, the nurse inspects the client's nose and concludes that the client has an infection. Which finding supports the nurse's conclusion? A. Bloody discharge B. Watery discharge C. Thick mucosal discharge D. Purulent and malodorous discharge

C. Thick mucosal discharge

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. What term should be used when documenting this assessment? A. Fine crackles B. Adventitious sounds C. Vesicular breath sounds D. Diminished breath sounds

C. Vesicular breath sounds

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray

C. white-out infiltrates bilaterally

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition? A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."

D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."

You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. "This pressure setting assists the patient with breathing in and out and helps improve air flow." B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."

D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."

A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related? A. >25 mmHg B. <10 mmHg C. >50 mmHg D. <18 mmHg

D. <18 mmHg

What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? A. Pectus carinatum B. Pectus excavatum C. Kussmaul breathing D. Cheyne-Stokes respirations

D. Cheyne-Stokes respirations

Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention? A. Treat the victim for shock. B. Start rescue breathing immediately. C. Apply surface pressure to the foot wound. D. Safely remove the victim from the immediate vicinity.

D. Safely remove the victim from the immediate vicinity.

The nurse understands that clients with emphysema experience which pathophysiologic change in the alveolar sacs? A. They collapse. B. They retain CO2. C. They become fluid filled. D. They become overdistended.

D. They become overdistended.

A client who works in the leather industry complains of a bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suggests the client consult a primary healthcare provider immediately. Which risk does the nurse suspect in the client? A. Epistaxis B. Facial trauma C. Fracture of the nose D. Tumor of the nasal cavity

D. Tumor of the nasal cavity