Med surge NCLEX questions- respiratory

A patient in the emergency department has esophageal trauma. Subcutaneous emphysema in the mediastinal area up to the lower part of the neck is palpated by the nurse. What is the priority action the nurse should take? A. A. Assess the patient's oxygenation status B. B. Obtain a STAT chest X-ray C. C. Prepare for immediate surgery D. D. Start two large-bore IVs

A. A. Assess the patient's oxygenation status

30. Tracheostomy skills are being practiced by a nursing student in the simulation lab. Which of the following student actions is an indication that additional teaching is necessary? A. Applying suction while inserting the catheter B. Preoxygenating the client prior to suctioning C. Suctioning for a total of three times, if needed D. Suctioning for only 10 to 15 seconds each time

A. Applying suction while inserting the catheter When suctioning a patient, suction is only applied during withdrawal of the suction catheter. The nursing student should apply suction intermittently and slowly rotate the catheter between the dominant thumb and forefinger as the catheter is withdrawn. This will prevent causing hypoxia.

1. A patient experiences dyspnea and has to stop several times when climbing stairs. When planning care for this patient, which intervention should be included by the nurse? A. Assistance with activities of daily living B. Physical therapy activities every day C. Oxygen therapy at 2 liters per nasal cannula D. Complete bedrest with frequent repositioning

A. Assistance with activities of daily living

11. A patient rescued from a house fire has sustained burns to the face and upper chest. As the patient arrives by ambulance, the nurse notes the patient has a bolus of L infusing and 4L/min 02 by face mask applied. Which of the following actions should be taken by the nurse first? A. Auscultate lung sounds B. Determine depth and extent of burns C. Infuse TPN with high-protein concentration D. Administer hydromorphone

A. Auscultate lung sounds Rationale: The patient with burns to the head, neck, upper back, chest or upper extremities is at high risk for inhalation injury or burns to the structures of the airway. The nurse should not assume that a thorough airway assessment has been made or that the oxygen face mask is effective for meeting oxygen needs. Assessment of the airway and breathing is the first action the nurse should take.

23. A nurse admits a new patient to the medical surgical unit. While assessing lung sounds, the nurse places the stethoscope over the trachea and larynx and hears a harsh, hollow sound. What is the first action the nurse should take? A. Document the findings B. Administer oxygen therapy C. Position the patient in high-Fowler's position D. Administer albuterol

A. Document the findings Rationale: Harsh, hollow sounds over the trachea and larynx are bronchial breath sounds and are a normal finding. This should be documented in the patient's chart. Documentation is appropriate when no other intervention is necessary and when no other direct patient care ions are available as answer choices.

28. A patient who had a tracheostomy placed four days ago is fed lunch by an unlicensed assistive personnel (UAP). That evening, the UAP tells the nurse the patient coughed frequently during lunch. What is the priority action by the nurse? A. Immediately assess the patient's lung sounds B. Assign a different patient to the UAP C. Report the UAP to the nursing supervisor D. Request thicker liquids for meals

A. Immediately assess the patient's lung sounds

17. A 55-year-old male patient has measurements of the anteroposterior (AP) and lateral chest diameter that are equal. Which question should be asked by the nurse? A. "Do you take any medications or herbal supplements?" B. "Do you have chronic breathing problems?" C. "How often do you exercise?" D. "Have you been exposed to any allergens lately?

B. "Do you have chronic breathing problems?"

24. A patient is on 2 liters per minute of oxygen via nasal cannula. The nursing student removes the oxygen according to the healthcare provider's order. The patient says, "I need that still, or I won't be getting any oxygen." What is the correct response by the student nurse? A. "If you desaturate or show signs of hypoxia, we will reapply the nasal cannula." B. "The room air is actually 21% oxygen. We will monitor you closely and make sure you are able to breathe without difficulty. " » C. "I think you will be ok without it." D. "The doctor ordered for the oxygen to be removed."

B. "The room air is actually 21% oxygen. We will monitor you closely and make sure you are able to breathe without difficulty.

15. The nurse is caring for a 68-year-old patient admitted for pulmonary infection. Which of the following actions should be taken by the nurse first? A. Encourage fluid intake B. Assess level of consciousness C. Raise head of bed to 60 degrees D. Provide humidified oxygen

B. Assess level of consciousness

A patient is in the emergency room after being stung by a bee. The patient is experiencing anxiety and difficulty breathing. What priority action should the nurse perform? A. Have the patient lie down B. Assess the patient's airway C. Administer high-flow oxygen D. Remove the stinger from the site

B. Assess the patient's airway

A nurse is preparing a patient for paracentesis. Which intervention is appropriate for the nurse delegate to an unlicensed assistive personnel (UAP)? A. Have the patient sign the informed consent B. Assist the patient to void before the procedure C. Help the patient lay flat in bed on the right side D. Get the patient into a chair after the procedure

B. Assist the patient to void before the procedure

35. Lunch has been delivered to a patient receiving oxygen via Venturi mask. What is the best action by the nurse? A. Assess the patient's oxygen saturation and, if normal, turn off the oxygen B. Determine if the patient can switch to a nasal cannula during the meal C. Have the patient replace the mask back on the face between bites of food D. Turn the oxygen off while the patient eats the meal and then restart it

B. Determine if the patient can switch to a nasal cannula during the meal Oxygen should be delivered constantly, and the nurse should check the patient's chart to see if switching this patient to a nasal cannula during meals has been approved. Otherwise, the nurse should contact the healthcare provider to discuss the issue.

31. A patient is placed on oxygen via nasal cannula in the hospital. When the nurse assesses the patient, which finding indicates the patient is meeting goals for a priority diagnosis? A. 100% of meals being eaten by the patient B. Intact skin behind the ears C. The patient understanding the need for oxygen D. Unchanged weight for the past three days

B. Intact skin behind the ears Anything that applies pressure to the skin, such as oxygen tubing, can cause pressure ulcers. If the skin behind the patient' ears is intact, this indicates a goal for the nursing diagnosis "risk for impaired skin integrity" is met.

27. The nurse discovers food particles when suctioning a patient's tracheostomy tube. What is the best action by the nurse? A. Elevate head of the patient's bed B. Measure and compare cuff pressures C. Place the patient on NPO status D. Request a swallow study

B. Measure and compare cuff pressures The patient may be suffering from tracheomalacia, a softening of the tracheal tissue and supporting tracheal cartilage. This can be a result of tissue necrosis caused by abnormally high tracheostomy cuff pressure. Tracheomalacia is often manifested by food in secretions. The nurse may also notice that greater pressure is needed to inflate the tracheostomy cuff than usual. The nurse should measure the current cuff pressure and compare it to previous pressures documented to determine if cuff pressure is high and how long it has been high. Normal cuff pressure is less than 25cm H20 (14-20 mmHg) and should generally be checked every eight hours.

22. A patient was administered benzocaine spray by the nurse before bronchoscopy earlier today. The patient now has low oxygen saturation levels and cyanosis, despite oxygen administration via non-rebreather. What is the next action the nurse should take? A. Administer an albuterol treatment B. Notify the rapid response team C. Assess the patient's peripheral pulses D. Increase the oxygen flow rate

B. Notify the rapid response team

33. The nurse in the oncology clinic cares for a patient diagnosed with throat cancer. The patient had a tracheostomy placed one week ago. Which assessment finding indicates that goals for the nursing diagnosis related to self-esteem are being met? A. The patient demonstrates good understanding of stoma care B. The patient has joined a book club that meets weekly at the library C. Family members take turns assisting with stoma care D. Skin around the stoma is intact without signs of infection

B. The patient has joined a book club that meets weekly at the library

39. A patient with a paralyzed vocal cord is educated by the nurse. For aspiration prevention, what technique does the nurse teach? A. Tilt the head back as far as possible when swallowing B. Tuck the chin down when swallowing C. Breathe slowly and deeply while swallowing D. Keep the head very still and straight while swallowing

B. Tuck the chin down when swallowing Patients who have paralyzed vocal cords in the open position are at risk for aspiration. Tucking in the chin when swallowing will prevent aspiration.

40. The nurse is assessing four patients on the medical-surgical unit. Which of the following patients does the nurse place at greatest risk for obstructive sleep apnea? A. 19-year-old who is eight months pregnant B. 65-year-old with gastroesophageal reflux disease (GERD) C. 42-year-old who is 60 pounds overweight D. 75-year-old with type 2 diabetes mellitus

C. 42-year-old who is 60 pounds overweight Obstructive sleep apnea is closure of the airway when sleeping due to excess weight and tissue. The patient at highest risk is overweight. The risk for sleep apnea is also higher in men with a neck circumference of 17 inches or more (16 inches or more for women) because a large neck has more soft tissue that can block the airway during sleep. Sleep apnea is more common between young adulthood and middle age and more common in men than women. Women's risk for sleep apnea increases with menopause.

20. The nurse is caring for a patient recovering from bronchoscopy two hours ago. When the patient asks for ice cream to soothe their sore throat, what is the next action the nurse should take? A. Notify the healthcare provider and request a diet order B. Give the patient ice chips C. Assess gag reflex before giving water D. Give the patient a sip to assess swallowing ability

C. Assess gag reflex before giving water Correct answer: C During a bronchoscopy, a flexible tube is inserted into the trachea. This procedure can be used for visualization of the lower airways, removal of a foreign object from the trachea/lungs, or sputum/tissue sample collection. A topical anesthetic is sprayed in the patient's throat, and the patient may be sedated for the procedure, which affects the patient's ability to swallow. The gag reflex should be checked before giving the patient anything by mouth.

25. The nurse prepares a patient for a tracheostomy procedure scheduled in one hour. What is the priority action by the nurse? A. Administer anxiolytic medication B. Obtain verbal consent for the procedure C. Reinforce pre-op teaching D. Start preoperative antibiotic infusion

C. Reinforce pre-op teaching Tracheostomy is an invasive surgical procedure in which a new opening is created into the trachea for an artificial airway to be inserted. After the healthcare provider explains the procedure and obtains signed consent, the nurse is responsible for reinforcing teaching about the procedure and what to expect afterwards.

29. Tracheostomy care for a patient is provided by the student nurse. During the procedure, which student action would require the instructor to intervene? A. Holding the device securely when changing ties B. Suctioning the patient prior to tracheostomy care C. Tying a square knot at the back of the neck D. Using half-strength hydrogen peroxide for cleansing

C. Tying a square knot at the back of the neck For patient safety, the knot should be placed at the side of the neck for easy access. This can also prevent pressure ulcers from forming at the back of the neck when the patient is laying supine.

A person in the public park is stung by a bee and encountered by a nurse. The person's lips are swollen and wheezes are easily heard. What is the first action the nurse should take? A. Elevate the site and notify the person's next of kin B. Remove the stinger with tweezers and encourage rest C. Administer topical diphenhydramine, apply ice, and call 911 D. Administer an EpiPen from the first aid kit

D. Administer an EpiPen from the first aid kit Swollen lips indicate anaphylaxis, and this is a true medical emergency. The EpiPen should be administered at the first sign of anaphylaxis, if available. Then the patient should be transported to the closest emergency room, and the nurse should frequently assess the airway while in transport.

18. A patient is scheduled for a thoracentesis this morning. Before the procedure, which intervention should be completed by the nurse? A. Measure oxygen saturation before and after a 12-minute walk B. Verify that the patient understands all possible complications C. Explain the procedure in detail to the patient and the family D. Validate that informed consent has been signed by the patient

D. Validate that informed consent has been signed by the patient Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is performed to remove excess fluid (pleural effusion) from the pleural space to facilitate easier breathing or send for biopsy. Informed consent is required before any invasive procedure. Complications may include pneumothorax, bleeding, bruising, infection, and, in rare cases, liver or spleen injuries.

26. A patient underwent surgical tracheostomy placement three days ago. While assessing the patient, the nurse discovers the face and eyelids are puffy and swollen. What is the priority action by the nurse? A. Assess the patient's oxygen saturation B. Notify the rapid response team C. Oxygenate the patient with a bag-valve-mask D. Palpate the skin of the upper chest

A. Assess the patient's oxygen saturation This patient has signs and symptoms of subcutaneous emphysema, air that leaks into tissues around the tracheostomy. Oxygenation status should be assessed by the nurse as priority.

A patient with hepatopulmonary syndrome is experiencing dyspnea, and his oxygen saturation level is 92%. He says he doesn't want to wear oxygen because it causes nosebleeds. He insists the nurse leave his room and leave him alone. Which action should the nurse take? A. Instruct the patient to sit as upright as possible B. Add humidity to the oxygen and encourage the patient to wear it C. Document the patient's refusal and notify the healthcare provider D. Contact the healthcare provider to request an additional dose of the patient's diuretic

A. Instruct the patient to sit as upright as possible

While in triage in a busy emergency room, the nurse assesses a patient who has symptoms of tuberculosis. Which is the first action the nurse should take? A. Place a mask on the patient and the nurse B. Administer intravenous 0.9% saline solution C. Transfer the patient to a negative pressure room D. Obtain a sputum culture and sensitivity

A. Place a mask on the patient and the nurse Tuberculosts is a highly contagious respiratory infection that is spread through airhorne means. When TB suspected, the nurse mast first place a mask on their own face and then The patients.

36. A patient is receiving 50% oxygen via Venturi mask. The nurse assesses the oxygen adjunct and notes the mask fits appropriately and oxygen is flowing at 3 L/min. What is the best action by the nurse? A. Assess the patient's oxygen saturation B. Document these findings in the chart C. Immediately increase the flow rate D. Turn the flow rate down to 2 L/min

C. Immediately increase the flow rate A Venturi mask is used to deliver a high flow of oxygen between 4 and 12 L/min. This type of oxygen delivery is used most often for critically ill patients who require a specific amount of oxygen administered. This patient's flow rate is low and should be increased by the nurse.

17. A patient is admitted to the emergency room with a nasal fracture. What is the first assessment the nurse should perform? A. Facial pain B. Vital signs C. Bone displacement D. Airway patency

D. Airway patency Maxillofacial fractures can potentially cause airway impairment. Assessing airway is more important than any other assessment answer choice. Other fractures that can impact airway include the clavicles, scapulae, ribs, and sternum.

38. A patient tells the nurse they are always tired upon waking, despite getting eight hours of sleep. What is the first action the nurse should take? A. Contact the provider for a prescription for sleep medication. B. Tell the patient not to drink beverages with caffeine before bed. C. Educate the patient to sleep upright in a reclining chair. D. Ask the patient if they have ever been evaluated for sleep apnea.

D. Ask the patient if they have ever been evaluated for sleep apnea. Sleep apnea interrupts normal breathing patterns during sleep, preventing the patient from getting a full night's rest, despite being in bed for eight hours. Many times, patients are not even aware of having sleep apnea. Persistently awaking tired is one of the classic symptoms of sleep apnea. Other conditions to evaluate for include depression, restless leg syndrome, and narcolepsy.

14. The nurse is assessing the health history of a patient. Which of the following data is highest priority for the nurse to collect when determining risks for respiratory disease? A. Daily fluid intake B. Neck circumference C. Height and weight D. Occupation and hobbies

D. Occupation and hobbies

A patient admitted for Pneumocystis jiroveci pneumonia reports activity-related shortness of breath and extreme fatigue. The nurse will promote comfort with which of the following interventions? A. Administer sleeping medication B. Perform most activities for the patient C. Increase the patient's oxygen during activity D. Pace activities, allowing for adequate rest

D. Pace activities, allowing for adequate rest

32. While assessing a patient, the nurse notes pulsation of the tracheostomy tube corresponding with the pulse rate. The nurse finds no other abnormal assessments. What is the most appropriate action by the nurse? A. Call the operating room to inform them of a pending emergency case B. No action is needed at this time; this is a normal finding C. Remove the tracheostomy tube and ventilate the patient with a bag-valve-mask D. Stay with the patient and have someone else call the provider immediately

D. Stay with the patient and have someone else call the provider immediately A trachea-innominate artery fistula may have formed, which is life-threatening. This is an abnormal connection between the patient's trachea and a nearby artery. Through this connection, blood from within the artery may pass into the trachea or alternatively, air from within the trachea may cross into the artery. This is a complication from prolonged endotracheal intubation, cuff over-inflation, or poorly-placed endotracheal tube. Primary threats are respiratory compromise or hemorrhage. The nurse should stay with the patient (provide respiratory support, assess for hemorrhage). The nurse can delegate another

The nurse cares for a patient following a thoracentesis procedure. The dressing is on the left side of the posterior thorax. Which finding requires immediate action? A. The patient rates pain as a 5/10 at the site of the procedure B. Serosanguinous drainage on dressing C. Pulse oximetry is 93% on 2 liters of oxygen D. The trachea is deviated toward the right side of the neck

D. The trachea is deviated toward the right side of the neck Tracheal deviation is a sign of tension pneumothorax-a medical emergency. Tension pneumothorax is collection of air or fluid in the pleural cavity that causes the affected lung to shift in the opposite direction, which also shifts the trachea.

34. A patient is receiving oxygen via nasal cannula. What task may be performed by the unlicensed assistive personnel (UP)? A. Applying water-soluble ointment to nares and lips B. Increasing the oxygen flow rate if the patient starts to decompensate C. Removing the tubing from the patient's nose D. Checking for reddened areas behind the ears where the cannula rests

A. Applying water-soluble ointment to nares and lips Water-soluble ointment helps with preventing the drying that occurs with oxygen administration. This task is within the scope of practice for the UAP.

3. The nurse is caring for a patient recovering after an open lung biopsy procedure. Which expected nursing assessment is matched with the correct nursing intervention? A. Patient has leaking fluid from needle site, so nurse applies a new, sterile dressing B. Patient's heart rate is 55 beats/min, so nurse withholds pain medication C. Patient has reduced breath sounds, so nurse calls physician immediately D. Patient's respiratory rate is 18 breaths/min, so nurse decreases oxygen flow rate

C. Patient has reduced breath sounds, so nurse calls physician immediately

A patient arrives in the emergency room with full-thickness burns to the lower extremities from a structure fire. The patient is occasionally disoriented, has a headache, and has 0.9 normal saline running at 100 ml hr through a peripheral IV. Which of the following actions should be taken by the nurse? A. Increase the patient's oxygen and obtain arterial blood gases B. Draw a blood sample for a carboxyhemoglobin level C. Change the fluid to Lactated Ringers and increase the infusion rate D. Perform a thorough Mini-Mental State Examination

C. Change the fluid to Lactated Ringers and increase the infusion rate Rationale: The emergent phase following a burn is the first 24-48 hours. The patient is likely to exhibit hypotension from fluid loss (from open wounds or extravasation into deeper tissues.) LR or plasma is infused rapidly over the first eight hours, and more slowly over the next 16 hours.

12. A patient with lung cancer informs the nurse he has a 50-pack/year smoking history. Which of the following nursing actions is best? A. Encourage the patient to quit smoking to stop further cancer development B. Encourage the patient to be completely honest about both tobacco and marijuana use C. Maintain a nonjudgmental attitude to avoid causing the patient to feel guilty D. Educate the patient about cancer treatment options and prognosis

C. Maintain a nonjudgmental attitude to avoid causing the patient to feel guilty

16. The nurse has just auscultated the patient's breath sounds. Which finding is matched correctly with the nurse's intervention? A. Hollow sounds heard over the trachea, so the nurse increases the oxygen flow rate B. Crackles are heard in bases, so the nurse administers beclomethasone inhaler C. Wheezes are heard in central areas, so the nurse administers bronchodilator inhaler D. Vesicular sounds are heard over the periphery, so the nurse has the patient breathe deeply

C. Wheezes are heard in central areas, so the nurse administers bronchodilator inhaler

A patient rescued from a house fire has burns on the arms, legs, and chest. Eight hours after admission, the patient has become restless and agitated. What is the first action the nurse should take? A. Remain at the bedside and comfort the patient B. Administer morphine IV C. Assess the patient's orientation and level of consciousness D. Check pulse oximetry for oxygenation status

D. Check pulse oximetry for oxygenation status The patient may have experienced smoke inhalation injury. Agitation is an indication of hypoxia. Pulse oximetry is the priority assessment as it gives here-and-now information about the patient's current respiratory status.

The nursing instructor is supervising several nursing students on the medical surgical floor. When a student asks why chronic obstructive pulmonary disease leads to polycythemia, what is the best response by the nursing instructor? A. It is due to side effects of medications for bronchodilation B. It is from overactive bone marrow in response to chronic disease C. It combats the anemia caused by an increased metabolic rate D. It compensates for tissue hypoxia caused by lung disease

D. It compensates for tissue hypoxia caused by lung disease Polycythemia is increase in red blood cell numbers in response to the lung disease. Red blood cells are produced in a response to hypoxia, which leads to more oxygen carrying capacity and ability to deliver oxygen to tissues.