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nclex 6 respiratory exam questions with answers and rationales., Exams of Nursing

nclex 6 respiratory exam questions with answers and rationales. nclex 6 respiratory exam questions with answers and rationales.

Typology: Exams

2024/2025

Available from 09/11/2024

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nclex 6 respiratory exam questions with

answers and rationales.

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

  1. Sims' position, with the head of the bed flat
    1. Prone, with the head turned to the side supported by a pillow
    2. Lying in bed on the affected side, with the head of the bed elevated 45 degrees
    3. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees - Correct Answer 4. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees Rationale: To facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the bed, leaning over a bedside table, with the feet supported on a stool or lying in bed on the unaffected side, with the head of the bed elevated 45 degrees (Fowler's position). Options 1, 2, and 3 are incorrect. The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take?
    4. Notify the Rapid Response Team.
    5. Finish the suctioning as quickly as possible.
    6. Contact the respiratory department to suction the client.
    7. Discontinue suctioning until the client is stabilized and monitor vital signs. - Correct Answer 4. Discontinue suctioning until the client is stabilized and monitor vital signs.

Rationale: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the registered nurse. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and health care provider may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified. The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply.

  1. Excessive bubbling in the water-seal chamber
  2. Vigorous bubbling in the suction-control chamber
  3. 50 mL of drainage in the drainage-collection chamber
  4. The drainage system is maintained below the client's chest.
  5. An occlusive dressing is in place over the chest-tube insertion site.
  6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation - Correct Answer 3. 50 mL of drainage in the drainage-collection chamber
  7. The drainage system is maintained below the client's chest.
  8. An occlusive dressing is in place over the chest-tube insertion site.
  9. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation Rationale: The bubbling of water in the water-seal chamber indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater

than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and requires registered nurse and health care provider notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?

  1. Empty the drainage.
  2. Encourage the client to deep breathe.
  3. Continue to monitor, because this is an expected finding.
  4. Encourage the client to hold his or her breath periodically. - Correct Answer 3. Continue to monitor, because this is an expected finding. Rationale: The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his or her breath. The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process?
  1. Stay very still.
  2. Exhale forcefully.
  3. Inhale and exhale quickly.
  4. Perform Valsalva's maneuver. - Correct Answer 4. Perform Valsalva's maneuver. Rationale: When the chest tube is removed, the client is asked to perform Valsalva's maneuver (i.e., take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options 1, 2, and 3 are incorrect client instructions. The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply.
  5. Pin the tubing to the bed linens.
  6. Be sure all connections remain airtight.
  7. Be sure all connections are taped and secure.
  8. Empty the drainage from the drainage collection chamber daily.
  9. Monitor closely for tubing that is kinked or obstructed by the weight of the client. - Correct Answer 2. Be sure all connections remain airtight.
  10. Be sure all connections are taped and secure.
  11. Monitor closely for tubing that is kinked or obstructed by the weight of the client. Rationale:

Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, lung collapse can occur. Options 2, 3, and 5 are appropriate interventions for the plan of care for a client with a chest tube. The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus?

  1. Asking the client about pain
  2. Checking the respirations hourly
  3. Checking the blood pressure every 2 hours
  4. Palpating for the leakage of air into the subcutaneous tissues - Correct Answer 4. Palpating for the leakage of air into the subcutaneous tissues Rationale: Subcutaneous emphysema is also known as crepitus. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. It is monitored by palpating, and it feels like bubble wrap when palpated. Although options 1, 2, and 3 may be components of the plan of care for a client with a chest tube, these actions will not identify subcutaneous emphysema. The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube?
  5. Enables the client to speak
  6. Prevents the client from speaking
  7. Is necessary for mechanical ventilation
  8. Prevents air from being inhaled through the tracheostomy opening - Correct Answer 1. Enables the client to speak

Rationale: A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. Options 2, 3, and 4 are incorrect with regard to this type of tube. The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?

  1. Side-lying in bed
  2. Sitting in a recliner chair
  3. Sitting up in bed at a 90 degree angle
  4. Sitting on the side of the bed, leaning on an overbed table - Correct Answer 4. Sitting on the side of the bed, leaning on an overbed table Rationale: Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. The positions in options 1, 2, and 3 will not enhance the effectiveness of breathing. The nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse should review the results of which diagnostic test to confirm this diagnosis?
  5. Chest x-ray
  6. Bronchoscopy
  7. Sputum culture
  8. Tuberculin skin test - Correct Answer 3. Sputum culture Rationale:

A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histologic evidence of granulomatous disease on biopsy. The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply.

  1. Activities should be resumed gradually.
  2. Avoid contact with other individuals, except family members, for at least 6 months.
  3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
  4. Respiratory isolation is not necessary because family members have already been exposed.
  5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.

When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment. - Correct Answer 1. Activities should be resumed gradually.

  1. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated.
  2. Respiratory isolation is not necessary because family members have already been exposed.
  3. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. Rationale:

The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. The client is also informed that activities should be resumed gradually. The client and family are informed that respiratory isolation is not necessary, because family members have already been exposed. The client is instructed about thorough hand washing and to cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. The client is informed that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment. The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which?

  1. Promote oxygen intake.
  2. Strengthen the diaphragm.
  3. Strengthen the intercostal muscles.
  4. Promote carbon dioxide elimination. - Correct Answer 4. Promote carbon dioxide elimination. Rationale: Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing. The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take?
  5. Administer oxygen.
  1. Ventilate the client manually.
  2. Check the client's vital signs.
  3. Start cardiopulmonary resuscitation (CPR). - Correct Answer 2. Ventilate the client manually. Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR. The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?
  4. Lateral position
  5. Low-Fowler's position
  6. Semi-Fowler's position
  7. Head of the bed elevation at 40 degrees - Correct Answer 1. Lateral position Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated. The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?
  8. Hypothermia
  1. Respiratory distress
  2. Hematoma in the left groin
  3. Discomfort in the left groin - Correct Answer 2. Respiratory distress Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure but does not indicate an allergic reaction. Discomfort is expected. The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?
  4. Fever
  5. Fatigue
  6. Weight loss
  7. Shortness of breath - Correct Answer 4. Shortness of breath Rationale: Shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss. The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?
  8. An uninsured man who is homeless
  9. A woman newly immigrated from Korea
  10. A man who is an inspector for the U.S. Postal Service
  1. An older woman admitted from a long-term care facility - Correct Answer 3. A man who is an inspector for the U.S. Postal Service Rationale: People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas, such as long-term care facilities, prisons, and mental health facilities; older clients; individuals with malnutrition, an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are intravenous drug users. The nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. Which interpretation should the nurse make of these results?
  2. Positive
  3. Negative
  4. Uncertain
  5. Borderline - Correct Answer 2. Negative Rationale: A positive Mantoux tuberculin skin test reading has an induration measuring 10 mm or more in diameter and indicates exposure to tuberculosis. A small area of ecchymosis is insignificant and is probably related to injection technique. Therefore, the remaining options are incorrect. The nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. Which action by the nurse is the priority?
  6. Report the findings.
  1. Document the finding in the client's record.
  2. Call the employee health service department.
  3. Call the radiology department for a chest x-ray. - Correct Answer 1. Report the findings. Rationale: The nurse who interprets a Mantoux tuberculin skin test as positive notifies the health care provider (HCP) immediately. The HCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be done to confirm the diagnosis of active TB. The client is placed on TB precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client. A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?
  4. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy.
  5. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy.
  6. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy.
  7. The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. - Correct Answer 4. The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy. Rationale: Family members or others who have been in close contact with a client diagnosed with TB are placed on prophylactic therapy with isoniazid for 6 to

12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant TB. The nurse is reinforcing discharge teaching with a client diagnosed with tuberculosis (TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood the information if which statement is made?

  1. "I can't shop at the mall for the next 6 months."
  2. "I need to continue medication therapy for 2 months."
  3. "I can return to work if a sputum culture comes back negative."
  4. "I should not be contagious after 2 to 3 weeks of medication therapy." - Correct Answer 4. "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client is generally considered to be not contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to employment when the results of three sputum cultures are negative. The nurse is caring for a client with emphysema receiving oxygen. The nurse should check the oxygen flow rate to ensure the client does not exceed how many L/min of oxygen?
  5. 1
  6. 2
  7. 6
  8. 10 - Correct Answer 2. 2 Rationale:

Between 1 and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system. The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.

  1. Apply suction for up to 10 to 15 seconds.
  2. Hyperoxygenate the client before suctioning.
  3. Set the wall suction unit pressure at 160 mm Hg.
  4. Apply suction while gently inserting the catheter.
  5. Apply intermittent suction while rotating and withdrawing the catheter.
  6. Advance the catheter until resistance is met and then pull the catheter back 1 cm. - Correct Answer 1. Apply suction for up to 10 to 15 seconds.
  7. Hyperoxygenate the client before suctioning.
  8. Apply intermittent suction while rotating and withdrawing the catheter.
  9. Advance the catheter until resistance is met and then pull the catheter back 1 cm. Rationale: Intermittent suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80 to 120 mm Hg. Pressure set at a higher level can cause

trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues. A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?

  1. Hypercalcemia
  2. Peripheral neuritis
  3. Small blood vessel spasm
  4. Impaired peripheral circulation - Correct Answer 2. Peripheral neuritis Rationale: An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.
  5. Hypocapnia
  6. Dyspnea on exertion
  7. Presence of a productive cough
  8. Difficulty breathing while talking
  9. Increased oxygen saturation with exercise
  10. A shortened expiratory phase of respiration - Correct Answer 2. Dyspnea on exertion
  11. Presence of a productive cough
  1. Difficulty breathing while talking Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough especially on arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?
  2. Skin color becomes cyanotic.
  3. Secretions are becoming bloody.
  4. Coughing occurs with suctioning.
  5. Heart rate decreases from 78 to 54 beats/minute. - Correct Answer 3. Coughing occurs with suctioning. Rationale: Coughing is a normal response to suctioning for the client with an intact cough reflex, and it is not an indication that the client is not tolerating the procedure. The client should be encouraged to cough to help with removal of secretions from the lungs. The nurse should monitor for the adverse effects of suctioning, which include cyanosis (pulse oximetry falls below 90% or 5% from baseline), excessively rapid or slow heart rate (a 20 beat/minute change), or the sudden development of bloody secretions. If they occur, the nurse stops suctioning, administers oxygen as appropriate, and reports these signs to the health care provider immediately. The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications?
  1. Decreasing oral fluid intake
  2. Monitoring the vital signs every shift
  3. Changing the client's position every 2 hours
  4. Instructing the client to bear down every hour and to hold his or her breath - Correct Answer 3. Changing the client's position every 2 hours Rationale: Frequent position changes help mobilize lung secretions and prevent pooling. This is the only intervention identified in the options that will prevent respiratory complications. The nurse should encourage fluid intake to thin secretions and thus enable the client to expectorate more easily. It is important to encourage coughing and deep breathing to mobilize lung secretions. The nurse should assess the client's vital signs every 4 hours to identify an elevated temperature, which may suggest infection. The client should be instructed to avoid the Valsalva maneuver or any activity that involves holding the breath. A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. The nurse develops a response to the client's question, based on which understanding?
  5. The disease is transmitted by droplet nuclei.
  6. The client should maintain enteric precautions only.
  7. Deep pile carpet should be removed from the home.
  8. Clothing and sheets should be bleached after each use. - Correct Answer 1. The disease is transmitted by droplet nuclei. Rationale: TB is spread by droplet nuclei or by the airborne route. The disease is not carried on objects such as clothing, eating utensils, linens, or furniture. Bleaching of clothing and linens is unnecessary, although the client and

family members should use good hand-washing technique. It is unnecessary to remove carpeting from the home. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience?

  1. Dyspnea
  2. Headache
  3. Weight gain
  4. Hypothermia - Correct Answer 1. Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well. The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles?
  5. Mask
  6. Gown
  7. Gloves
  8. Eye protection - Correct Answer 1. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. The other options are not necessary.

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery?

  1. Obturator
  2. Oral airway
  3. Epinephrine
  4. Tracheostomy tube with the next larger size - Correct Answer 1. Obturator Rationale: A replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times, in case the tracheostomy tube is dislodged. In addition, a curved hemostat that could be used to hold the trachea open, if dislodgment occurs, should also be kept at the bedside. An oral airway and epinephrine would not be needed. The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention?
  5. Suction the client.
  6. Check for a disconnection.
  7. Notify the respiratory therapist.
  8. Evaluate the tube cuff for a leak. - Correct Answer 1. Suction the client. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely caused by an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucous plugging requiring suctioning. It is also important to check the tubing for the presence of any water and determine whether the client is out of rhythm with breathing with the ventilator. A disconnection or a cuff leak can result in the sounding of

the low-pressure alarm. The respiratory therapist should be notified if the nurse could not determine the cause of the alarm. The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen?

  1. Have the client take three deep breaths.
  2. Limit fluids before obtaining the specimen.
  3. Ask the client to obtain the specimen after eating.
  4. Ask the client to spit into the collection container. - Correct Answer 1. Have the client take three deep breaths. Rationale: To obtain a sputum specimen, the client should brush his or her teeth to reduce mouth contamination. The client should then take three deep breaths and cough into a sputum specimen container. The client should be encouraged to cough and not spit so that sputum can be obtained. Sputum can be thinned by fluids or by a respiratory treatment, such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning. The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?
  5. Bradypnea
  6. Shortness of breath
  7. A low respiratory rate
  8. The presence of a barrel chest - Correct Answer 2. Shortness of breath Rationale: The client has sustained a blunt or a closed chest injury. This type of injury can result in a closed pneumothorax. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger

pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side. The presence of a barrel chest is characteristic of chronic obstructive pulmonary disease or emphysema. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect the client to experience?

  1. Hypocapnia
  2. Hyperinflated lungs on chest x-ray
  3. Increased oxygen saturation with exercise
  4. A widened diaphragm noted on chest x-ray - Correct Answer 2. Hyperinflated lungs on chest x-ray Rationale: Signs/symptoms of chronic obstructive pulmonary disease include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?
  5. The client breathes in through the mouth.
  6. The client breathes out slowly through the mouth.
  7. The client avoids using the abdominal muscles to breathe out.
  8. The client puffs out the cheeks when breathing out through the mouth. - Correct Answer 2. The client breathes out slowly through the mouth. Rationale:

Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, to inhale before beginning the activity, and to exhale while performing the activity. The client should never hold his or her breath. The nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with tuberculosis (TB). The nurse should expect to note which finding?

  1. High fever
  2. Flushed skin
  3. Complaints of weight gain
  4. Complaints of night sweats - Correct Answer 4. Complaints of night sweats Rationale: The client with tuberculosis usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease. The nurse provides instructions to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use if the client makes which statement? 1."I need to sit upright when using the device."
  5. "I will inhale slowly, maintaining a constant flow."
  6. "I need to place my lips completely over the mouthpiece."
  1. "After maximal inspiration, I will hold my breath for 10 seconds and then exhale." - Correct Answer 4. "After maximal inspiration, I will hold my breath for 10 seconds and then exhale." Rationale: For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips. The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make?
  2. There is a leak in the system.
  3. The chest tube is functioning as expected.
  4. The amount of suction needs to be decreased.
  5. The occlusive dressing at the insertion site needs reinforcement. - Correct Answer 2. The chest tube is functioning as expected. Rationale: The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. The remaining options are incorrect interpretations of the finding. The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next?
  1. Replace the chest tube system.
  2. Obtain a pulse oximetry reading.
  3. Notify the registered nurse (RN).
  4. Place the client in Trendelenburg's position. - Correct Answer 3. Notify the registered nurse (RN). Rationale: If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and notifies the RN, who then calls the health care provider (HCP). The nurse should maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings should assist in determining the client's respiratory status, but the priority action should be to notify the RN, who will then call the HCP. A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?
  5. Apply the sensor to a finger that is cool to the touch.
  6. Apply the sensor to a finger with very dark nail polish.
  7. Ask the client to limit motion in the hand attached to the pulse oximeter.
  8. Place the sensor distal to an intravenous (IV) site with a continuous IV infusion. - Correct Answer 3. Ask the client to limit motion in the hand attached to the pulse oximeter. Rationale: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. If

possible, the nurse should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement. The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

  1. Clamp the chest tubes.
  2. Empty the drainage system.
  3. Disconnect the drainage system.
  4. Administer pain medication 15 to 30 minutes before the procedure. - Correct Answer 4. Administer pain medication 15 to 30 minutes before the procedure. Rationale: Removal of chest tubes can be uncomfortable for a client. The nurse should medicate the client 15 to 30 minutes before the chest tube is removed. The remaining options are inappropriate actions and would not be performed by the nurse. The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter?
  5. 10 seconds
  6. 25 seconds
  7. 30 seconds
  8. 35 seconds - Correct Answer 1. 10 seconds Rationale: During suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client.