Respiratory ATI/NCLEX Questions

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?

a. Rhonchi on inspiration
b. Elevated temp
c. Barrel-shaped chest
d. Diminished breath sounds

Elevated temp

* It can indicate a possible respiratory infection.

The others are expected findings of patient’s with emphysema.

A nurse is caring for a pt who is post-op and has a RR of 9/min s/t general anesthesia effects & incisional pain. Which of the following ABG values indicated the pt is experiencing respiratory acidosis?

a. pH 7.50, PO2 95, PaCO2 25, HCO3 22

b. pH 7.50, PO2 87, PaCO2 35, HCO3 30

c. pH 7.30, PO2 90, PaCO2 35, HCO3 20

d. pH 7.30, PO2 80, PaCO2 55, HCO3 22

d. pH 7.30, PO2 80, PaCO2 55, HCO3 22

A nurse is caring for a newly-admitted pt who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?

a. Lateral position with a pillow at the back & over the chest to support the arm

b. High-Fowler’s position with the arms supported on the over-bed table

c. Semi-Fowler’s position with pillows supporting both arms

d. Supine position with the HOB elevated to 15

b. High-Fowler’s position with the arms supported on the over-bed table

* Allows for greater expansion of the chest (kind of tripod)

A nurse in the ED is caring for a client who is experiencing acute respiratory failure. Which of the following lab findings should the nurse expect?

a. Arterial pH 7.50
b. PaCO2 25 mmHg
c. SaO2 92%
d. PaO2 58 mmHg

d. PaO2 58 mmHg

* Expect the client who has acute respiratory failure to have lower partial pressures of O2

A nurse is providing discharge teaching to a pt who has pulmonary TB & a new prescription for rifampin. Which of the following instructions should the nurse include?

a. “Ringing in the ears is an adverse effect”

b. “Have your skin test repeated in 4 months to a show a positive result”

c. “Expect your urine and other secretions to be orange while taking this medication”

d. “Remember to take this medication with a sip of water just before your first bite of each meal”

c. “Expect your urine and other secretions to be orange while taking this medication”

* Rifampin is hepatotoxic, so the nurse should also instruct the pt to notify the provider if manifestations of hepatitis occur including jaundice, fatigue, or malaise

* Can also cause GI disturbances

* Should be taken 1 hour BEFORE or 2 hours AFTER a meal

* PPD skin test results will continue to show positive even after the disease is no longer active

A nurse working in the ED is caring for a pt following an acute chest trauma. Which of the following findings indicates to the nurse the client is possible experiencing a tension pneumothorax?

a. Collapsed neck veins on the affected side

b. Collapsed neck veins on the unaffected side

c. Tracheal deviation to the affected side

d. Tracheal deviation to the unaffected side

d. Tracheal deviation to the unaffected side

* A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side

* DISTENDED neck veins are an expected finding of a tension pneumothorax

A nurse in a provider’s office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider?

a. Increased AP chest diameter
b. Productive cough with green sputum
c. Clubbing of the fingers
d. Pursed-lip breathing with exertion

b. Productive cough with green sputum

* Green sputum can indicate infection

* The color comes from WBC. At first, may notice yellow phlegm that then progresses into green. The change occurs with the severity and length of the potential sickness. Commonly caused by: bronchitis, pneumonia, & sinusitis.

A nurse is assisting the provider who is performing a thoracentesis at the bedside of a pt. Which of the following actions should the nurse take?

Select all that apply

a. Wear goggles and mask during the procedure

b. Cleanse the procedure area with an antiseptic solution

c. Instruct the client to take deep breaths through the procedure

d. Position the client laterally on the affected side before the procedure

e. Apply pressure to the site after the procedure

a. Wear goggles and mask during the procedure

* reduces the risk of exposure to pleural fluid

b. Cleanse the procedure area with an antiseptic solution

* antiseptics are antimicrobial substances that are applied to living skin/tissue to reduce risk of infection

e. Apply pressure to the site after the procedure

* decreases risk of bleeding at procedure site

The nurse should instruct the pt to remain as still as possible during to reduce the risk of puncturing the pleura or lung.

The pt should be positioned in a sitting position leaning over the bedside table or laterally on the UNAFFECTED side to promote access to the site and encourage draining of pleural fluid

A nurse is caring for a pt who has a pulmonary embolism. Which of the following interventions is the priority?

a. Provide a quiet environment

b. Encourage use of incentive spirometer every 1-2 hours

c. Obtain a blood sample for electrolyte study

d. Administer heparin via continous IV infusion

d. Administer heparin via continous IV infusion

* Priority is stabilizing circulation t lungs, which is achieved by administering heparin to prevent further clot formation

Should also,

provide quiet environment to promote rest and conserve oxygen; encourage incentive spirometer use; get blood sample for coagulation studies, electrolyte levels, and a CBC

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?

a. Extra drainage system
b. Suture removal set
c. Container of sterile water
d. Non-adherent pads

c. Container of sterile water

* Plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax

* Should empty the collection chamber in the drainage system or replace it before the drainage reaches the bottom of the tube so don’t need extra drainage set

* Should provide non-adherent, air tight sterile petrolatum gauze when the chest tube is removed. If the chest tube is accidentally removed, the nurse should cover the wound with DRY sterile gauze.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery systems should the nurse use to provide the client with the highest level of oxygen?

a. Nasal cannula
b. Non-rebreather mask
c. Simple face mask
d. Partial rebreather mask

b. Non-rebreather mask

* Made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FiO2!

A nurse is caring for four clients. Which of the following client is at greatest risk for pulmonary embolism?

a. 48 hours post-op following a total hip arthroplasty

b. 8 hours post-op following an open surgical appendectomy

c. 2 hours post-op following an open reduction external fixation of the right radius

d. 4 hours post-op following a laparoscopic cholecystectomy

a. 48 hours post-op following a total hip arthroplasty

* Total hip replacement is greatest risk due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?

a. Cromolyn sodium
b. Prednisone
c. Fluticasone/salmeterol
d. Albuterol

d. Albuterol

* Rescue bronchodilator

Cromolyn sodium: anti-inflammatory agent for maintenance therapy

Prednisone: administer following an acute attack to promote anti-inflammatory effects

Fluticasone/salmeterol: maintenance therapy of asthma because it combines a glucocorticoid and a LABA

A nurse is assessing a client who is 4 hours post-op following a total laryngectomy. Which of the following findings is the priority to report to the provider?

a. Bleeding at the surgical site
b. Decreased oxygen saturation
c. Urinary retention
d. Increased pain level

b. Decreased oxygen saturation

* This procedure = higher risk for hypoxia due to airway obstruction

A nurse in the ED is caring for a pt who is experiencing a pulmonary embolism. Which of the following actions should the nurse first take?

a. Apply supplemental oxygen
b. Increase the rate of IV fluids
c. Administer pain medication
d. Initiate cardiac monitoring

a. Apply supplemental oxygen

* great risk of severe hypoxemia

Afterwards, should also increase the rate of IV fluid to increase cardiac output; initiate cardiac monitoring because of risk for dysrhythmias & right ventricle failure; administer pain medications to decrease discomfort and anxiety

A nurse is caring for a pt who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?

a. Hyperkalemia
b. Dyspnea
c. Tachycardia
d. Candidiasis

c. Tachycardia

* Albuterol can cause HYPOkalemia

* Candidiasis is r/t inhaled glucocorticoids, such as beclomethasone

A nurse is preparing a pt for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments?

a. Presence of gag reflex
b. Pain level rating use 0-10 scale
c. Hydration status
d. Appearance of the IV insertion site

a. Presence of gag reflex

* Greatest risk to pt is aspiration due to depressed gag reflex.

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect?

a. Decreased fremitus
b. SaO2 95% on room air
c. Temp 101.8 F
d. Bradypnea

c. Temp 101.8 F

* Pt would have INCREASED fremitus & tachypnea

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?

a. Fluctuation of draining in tubing with inspiration

b. Continuous bubbling in water seal chamber

c. Drainage of 75 mL in the first hour after surgery

d. Several small, dark-red blood clots in the tubing

b. Continuous bubbling in water seal chamber

* Suggests an air leak

A nurse is caring for a pt who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take?

a. Use clean technique when suctioning the pt’s ET tube

b. Use a rotating motions when removing the suction catheter

c. Suction the oropharyngeal cavity prior to suctioning the ET tube

d. Suction the client’s ET tube every 2 hours

b. Use a rotating motions when removing the suction catheter

* reduces risk of tissue trauma

* suction ET tube prior to the non-sterile oropharyngeal cavity to prevent cross-contamination

* only suction as needed because routing suctioning can result in hypoxia, tissue damage, bleeding, and bronchospasms

A nurse is caring for a pt who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?

a. Excess secretions
b. Kinks in the tubing
c. Artificial airway cuff leak
d. Biting on the endotracheal tube

c. Artificial airway cuff leak

* Interferes with oxygenation and causes low pressure alarm to sound

The others cause the high pressure alarm to sound

A nurse is assessing a client who has acute respiratory distress syndrome. Which of the following findings should the nurse report to the provider?

a. Decreased bowel sounds
b. O2 sat 92%
c. CO2 24
d. Intercostal retractions

d. Intercostal retractions

Indicates increasing respiratory compromise

A nurse is providing teaching to a pt who has chronic asthma and a new prescription to montelukast. Which of the following client statements indicates an understanding of the teaching?

a. “I will monitor my HR every day”

b. “I will make sure I have this medication with me at all times”

c. “I will need to carefully rinse my mouth after I take this medication”

d. “I will take this medication every night even if I don’t have symptoms”

d. “I will take this medication every night even if I don’t have symptoms”

* prophylactic treatment and is taken on a daily basis in the evening

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?

a. BP
b. Capillary refill
c. ABGs
d. HR

c. ABGs

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four pts. For which of the following puts should the nurse clarify the provider’s prescription?

a. Client who has epistaxis
b. Client who has amyotrophic lateral sclerosis
c. Client who has pneumonia
d. Client who has emphysema

a. Client who has epistaxis

May cause an increase in bleeding!

A nurse is caring for a client who is 1 hour post-op following a thoracentesis. Which of the following is the priority assessment finding?

a. Pallor
b. Insertion site pain
c. Persistent cough
d. Temp 99.1 F

c. Persistent cough

* Indicates tension pneumothorax

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect?

a. Blood-tinged sputum
b. Decreased tactile fremitus
c. Resonance with percussion
d. Peripheral edema

a. Blood-tinged sputum

* s/t bleeding from the tumor

Should expected INCREASED tactile fremitus due to tumor tissue or fluid replacing airspaces

Should expect dullness or flat sounds

A nurse is providing discharge teaching to a pt who has a temp tracheostomy. Which of the following statements by the pt indicates an understanding of the teaching?

a. “I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma”

b. “I should cut a 4″ gauze dressing and place it around my trach tube to absorb drainage”

c. “I should remove the old twill ties after the new ties are in place”

d. “I should apply suction while inserting the catheter into my trach tube”

c. “I should remove the old twill ties after the new ties are in place”

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

a. Schedule respiratory treatments following meals

b. Have the client sit up in a chair for 2 hour periods TID

c. Provide a diet that is high in calories and protein

d. Combine activities to allow for longer rest periods between activities

c. Provide a diet that is high in calories and protein

* Low in carbs!

* Respiratory treatments BEFORE meals

* Schedule periods of short activity with adequate rest periods between

The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting:

A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base

D. The fingernail and its base

Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment?

A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions

A. Hyperthermia related to infectious illness

Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

How does atelectasis reduce gas exchange?

a. Airway obstruction
b. Reduced alveolar surface area
c. Failure of pulmonary circulation to fully perfuse lung tissue
d. Increased bronchial secretions filling the alveoli with fluid rather than with air

b. Reduced alveolar surface area

In performing a chest assessment, the nurse observes or determines all of the following findings on a 70 yo client. Which finding indicates to the nurse that the client may have an increased residual lung volume?

a. Exhalation is twice as long as inhalation
b. Breath sounds are absent at the lung edges
c. The intercostal spaces measure 4 cm
d. Vibrations can be felt on the chest wall when the client speaks

c. The intercostal spaces measure 4 cm

Normally should be ~2 cm apart. Increases with air-trapping.

The client’s oxygen saturation by pulse oximetry on the finger is 84%. What is the nurse’s best first action?

a. Recheck the value on the forehead
b. Assess the client’s cognitive function
c. Notify the RRT immediately
d. Apply supplemental oxygen by mask or nasal cannula

a. Recheck the value on the forehead

When patients have any degree of impaired peripheral blood flow, the most accurate place to test oxygen saturation is on the forehead.

Results lower than 91% require emergency and immediate assessment and treatment. When below 85%, body tissues have a difficult time becoming oxygenated. Below 70% is usually life-threatening.

Pulse ox is less accurate at lower values.

The client, in a panicky voice, tells the nurse during a thoracentesis that he feels as if he is being pushed off the table. What is the nurse’s best response?

a. Stop the procedure to administer an anxiety-reducing drug
b. Remind the patient not to talk or breathe during the procedure
c. Reassure the client that this is a normal sensation as the needle is inserted into the chest cavity
d. Relay this information to the provider performing the procedure so that the needle can be repositioned

c. Reassure the client that this is a normal sensation as the needle is inserted into the chest cavity

* pt may feel burning sensation, too

b. pt should not move, but can breathe

Which action does the nurse take to prevent hypoxia in a client during nasotracheal suctioning?

a. Measuring the pulse oximetry throughout the procedure
b. Inserting the suction catheter through the vocal cords only when the client exhales
c. Administering 100% oxygen by manual resuscitation bag before initiating suctioning
d. Removing the suction tube from the nasopharynx as soon as the client coughs

c. Administering 100% oxygen by manual resuscitation bag before initiating suctioning

* pre oxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least 3 hyper-inflations) to prevent hypoxemia. Keep hyper-inflations synchronized with inhalation. If the patient can take deep breaths, instruct them to do so 3-4 times before suctioning

a. while you do want to measure pulse oximetry if possible, it isn’t critical to do so and doesn’t prevent hypoxia… it identifies it. If the oxygen saturation falls below 90%, hypoxia is indicated.

b. insert the suction catheter through the vocal cords on INHALATION

d. the client may cough once the catheter enters the larynx. wait for them to inhale, then advance the catheter through the vocal cords and into the trachea. do NOT remove the suction tube!

Why can oxygen therapy cause hypoventilation in clients who have hypercarbia?

a. Low arterial oxygen levels are the neurologic trigger for these patients to breathe

b. Excessive CO2 levels reduce the ability of hemoglobin molecules to carry oxygen

c. High concentrations of oxygen cause sedation, which reduces the strength of respiratory muscle contractions

d. unlike people who do not have hypercarbia, these clients are no longer sensitive to changing levels of arterial oxygen

a. Low arterial oxygen levels are the neurologic trigger for these patients to breathe

*unlike people who do not have hypercarbia (which receive drive to breathe based on CO2 levels), these patients rely on low arterial oxygen levels to stimulate the respiratory centers in the pons and medulla oblongata. If they’re on oxygen therapy at too high of levels or for too long, they lose the drive to breathe.

* a patient who is hypoxemia and has chronic hypercarbia needs lower levels of oxygen delivery (usually 1-2 L/min) via nasal cannula to prevent decreased respiratory effort.

Which action is most important for the nurse to teach the family of a client who is receiving oxygen therapy at home by continuous nasal cannula?

a. Providing mouth care every 8 hours
b. Lubricating the lips with water-soluble jelly
c. Draining the condensation in the tubing every 2 hours
d. Changing the position of the elastic band every 4 hours

d. Changing the position of the elastic band every 4 hours

* skin breakdown is a risk. should be cleansing band and skin underneath frequently & padding underneath along with changing the position to prevent skin breakdown from occurring

a., b., & c. are appropriate but not the most critical

Which technique or action does the nurse use to prevent tracheal stenosis in a client after a tracheotomy has been performed?

a. Assessing breath sounds bilaterally every 2 hours
b. Securing the trach tube in midline position
c. Holding the tube continually when changing the trach ties
d. Suctioning the trach tube with as small a catheter as possible

b. Securing the trach tube in midline position
* if not midline and irritating tissues, it will cause prolonged inflammation, leading to narrowing of airway

a. perform a complete respiratory assessment at least every 2 hours

c. take off the old ties after the new ones are secured to ensure the tube does not move

d. suction the trach tube with a catheter that does not exceed half of the size of the tracheal lumen, but if too small then won’t work efficiently

A client who works in a furniture factory reports that he is worried about his health because two co-workers have been diagnosed with sinus cancer in the past year. Which suggestion does the nurse make to reduce this client’s risk for sinus cancer?

a. Avoid the use of OTC nasal sprays
b. Wear a fine particulate mask when working with wood
c. Spend as much time as possible outdoors, away from cities
d. Wear gloves when working with paint thinners and liquid glue

b. Wear a fine particulate mask when working with wood
*more common with people that experience chronic exposure to wood dusts; peak incidence is 40-45 for men & 60-65 for women; higher in Asian Americans; manifestations resemble sinusitis

a. encourage nasal spray use!

Which nursing action has the highest priority when caring for a client with facial trauma?

a. Managing pain
b. Providing nutrition
c. Assessing self-image
d. Maintaining a patent airway

d. Maintaining a patent airway

A client with leukoplakia just above the glottis has just received the results of a biopsy and is confirmed to have squamous cell carcinoma in situ. She begins to cry and says that she would not be able to stand a surgery that would take away her ability to speak. What is the nurse’s best response?

a. “Your loss of speech would only be temporary until you learned to use esophageal speech”

b. “Cancers at this stage are usually treated with chemotherapy alone, which does not permanently affect your ability to speak”

c. “Cancers at this stage are usually treated with radiation alone, which does not permanently affect your ability to speak”

d. “A speech and language pathologist will work with you to select the method of communication that fits your lifestyle best”

c. “Cancers at this stage are usually treated with radiation alone, which does not permanently affect your ability to speak”

* squamous cell carcinoma in situ (aka Bowmen’s disease) is the earliest stage; “in situ” means the cancer is still within the cells

* reassure the patient that voice improves within 4-6 weeks after completion of radiation therapy

The spouse of a client who has had a partial vertical laryngectomy is working with the client to use the supraglottic method of swallowing. Which direction given by the spouse to the client indicates to the nurse that more instruction is needed?

a. Sit up as straight as you can while eating
b. Clear your throat before taking a bite of food
c. Only take a teaspoonful of food at a time
d. Swallow once, then take a breath, and swallow again

d. Swallow once, then take a breath, and swallow again

* after placing 1/2 to 1 tsp of food into mouth, hold breath or bear down, swallow twice, then release breath and clear throat followed by swallowing twice more

A client reaches for the salmeterol (Serevent) inhaler with the onset of an asthma attack. What is the nurse’s best action?

a. Instruct the client to use the albuterol (Proventil) inhaler instead

b. Assist the client to use oxygen for 3 breaths between the two puffs of the inhaled drug

c. Instruct the client to attach the space to the inhaler before using it and inhale as rapidly as possible

d. Remind the client to take a deep breath, hold it for 15 seconds, and then exhale before using the inhaler

a. Instruct the client to use the albuterol (Proventil) inhaler instead

* salmeterol (Serevent) is a LABA, so it needs time to build up an effect. The patient needs to use a SABA (albuterol) during an attack.

The client with severe dyspnea has all of the following ABG values. Which one does the nurse report immediately to the provider?

a. pH = 7.18
b. HCO3- = 31 mEq/L
c. PaCO2 = 68 mmHg
d. PaO2 = 68 mmHg

d. PaO2 = 68 mmHg

Which assessment finding indicates to the nurse that the client with COPD needs to be suctioned?

a. Documentation indicates the client was last suctioned 12 hours ago

b. The client is unable to speak more than 6 words without clearing throat

c. Although the client is coughing, breath sounds indicate continued presence of secretions in airways

d. The oxygen saturation decreases while the client performs controlled coughing

c. Although the client is coughing, breath sounds indicate continued presence of secretions in airways

* Perform suctioning only as needed, not on a routine schedule.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A: Alcoholism and hypertension B: Obesity …

a. Asthma A client is diagnosed with a pulmonary disorder that causes COPD. Lungs tissue changes are normally reversible with this condition. The nurse understands that which is the client’s most likely diagnosis? a. Asthma b. Emphysema c. Bronchiectasis d. …

A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route? Increase infection rates A nurse is planning care for a client who has had stroke resulting in aphasia and dysphagia. Which …

A nurse is caring for a client who has lung cancer. which of the following assessment findings should the nurse expect? Blood-tinged sputum A nurse is caring for a client who is 4 hr postoperative following a total laryngectomy for …

The nurse is caring for a client who has undergone cardiac catheterization. The client says to the nurse, “The doctor said my cardiac output was 5.5 L/min. What is normal cardiac output?” Which of the following is the nurse’s best …

The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a. Place the end of the chest tube in a container of sterile …

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