NCLEX Nursing Practice Questions On Respiratory System Disorders
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- 1.
While changing the tapes on a tracheostomy tube. the male client coughs and tube is dislodged. The initial nursing action is to:
- A.
Call the physician to reinsert the tube
- B.
Grasp the retention sutures to spread the opening
- C.
Call the respiratory therapy department to reinsert the tracheotomy
- D.
Cover the tracheostomy site with a sterile dressing to prevent infection
Correct Answer
B. Grasp the retention sutures to spread the openingExplanation
If the tube is dislodged accidentally. the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits. the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation.Rate this question:
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- 2.
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
- A.
Stridor
- B.
Occasional pink-tinged sputum
- C.
A few basilar lung crackles on the right
- D.
Respiratory rate 24 breaths/min
Correct Answer
A. StridorExplanation
The nurse reports stridor to the physician immediately. This is a high-pitched. coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B. C. and D are not signs that require immediate notification of the physician.Rate this question:
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- 3.
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?
- A.
A low respiratory rate
- B.
Diminished breath sounds
- C.
The presence of a barrel chest
- D.
A sucking sound at the site of injury
Correct Answer
B. Diminished breath soundsExplanation
This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea. cyanosis. diminished breath sounds. and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.Rate this question:
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- 4.
Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?
- A.
Hypocapnia
- B.
A hyperinflated chest noted on the chest x-ray
- C.
Increased oxygen saturation with exercise
- D.
A widened diaphragm noted on the chest x-ray
Correct Answer
B. A hyperinflated chest noted on the chest x-rayExplanation
Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia. hypercapnia. dyspnea on exertion and at rest. oxygen desaturation with exercise. and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.Rate this question:
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- 5.
An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
- A.
Face tent
- B.
Venturi mask
- C.
Aerosol mask
- D.
Tracheostomy collar
Correct Answer
B. Venturi maskExplanation
The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent. aerosol mask. and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.Rate this question:
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- 6.
Blessy. a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
- A.
Dyspnea
- B.
Chest pain
- C.
A bloody. productive cough
- D.
A cough with the expectoration of mucoid sputum
Correct Answer
D. A cough with the expectoration of mucoid sputumExplanation
One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A. B. and C are late symptoms and signify cavitation and extensive lung involvement.Rate this question:
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- 7.
A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?
- A.
Bronchoscopy
- B.
Sputum culture
- C.
Chest x-ray
- D.
Tuberculin skin test
Correct Answer
B. Sputum cultureExplanation
Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test. a sputum smear that is positive for acid-fast bacteria. a chest x-ray. and histological evidence of granulomatous disease on biopsy.Rate this question:
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- 8.
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:
- A.
1 L/min
- B.
2 L/min
- C.
6 L/min
- D.
10 L/min
Correct Answer
B. 2 L/minExplanation
Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema. the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels. as is the case in a normal respiratory system.Rate this question:
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- 9.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds. knowing that the primary purpose of pursed-lip breathing is to:
- A.
Promote oxygen intake
- B.
Strengthen the diaphragm
- C.
Strengthen the intercostal muscles
- D.
Promote carbon dioxide elimination
Correct Answer
D. Promote carbon dioxide eliminationExplanation
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A. B. and C are not the purposes of this type of breathing.Rate this question:
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- 10.
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?
- A.
Pallor
- B.
Low arterial PaO2
- C.
Elevated arterial PaO2
- D.
Decreased respiratory rate
Correct Answer
B. Low arterial PaO2Explanation
The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored. and the client may exhibit air hunger. retractions. and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia. with a PaO2 lower than 60 mm Hg.Rate this question:
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Nov 16, 2023Quiz Edited by
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Sep 22, 2017Quiz Created by
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