Nclex 3

EXCLUSIVELY FOR PBL-B6.
Question:
A client who takes theophylline for chronic obstructive pulmonary disease is seen in
the urgent care center for respiratory distress. Once the client is stabilized, the
nurse begins discharge teaching. The nurse would be especially vigilant to include
information about complying with medication therapy if the client s baseline
theophylline level was:
Options:
1. 10 mcg/mL
2. 12 mcg/mL
3. 15 mcg/mL
4. 18 mcg/mL
Answer:
1.
Rationale:
The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the
level is below the therapeutic range, the client may experience frequent
exacerbations of the disorder. Although all the options identify values within the
therapeutic range, option 1 is the option that reflects a need for compliance with
medication.
Level of Cognitive Ability - Comprehension
Client Needs - Physiological Integrity
Integrated Process - Teaching and Learning
Content Area - Adult HealthRespiratory
Strategy:
Use the process of elimination. Note the strategic words especially vigilant .
Recalling the therapeutic level of theophylline will direct you to option 1. Review this
therapeutic range if you had difficulty with this question.
Reference:
Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th
ed., p. 1040). Philadelphia: W.B. Saunders.
page 1 Elsevier items and derived items 2008 by Saunders, an imprint of Elsevier
Inc.
Some material was previously published.
Question:
A nurse caring for a client with a pneumothorax and who has had a chest tube
inserted notes continuous gentle bubbling in the suction control chamber. What
action is appropriate?
Options:
1. Do nothing, because this is an expected finding.
2. Immediately clamp the chest tube and notify the physician.
3. Check for an air leak because the bubbling should be intermittent.
4. Increase the suction pressure so that the bubbling becomes vigorous.

Answer:
1.
Rationale:
Continuous gentle bubbling should be noted in the suction control chamber. Option
2 is incorrect. Chest tubes should only be clamped to check for an air leak or when
changing drainage devices (according to agency policy). Option 3 is incorrect.
Bubbling should be continuous and not intermittent. Option 4 is incorrect because
bubbling should be gentle. Increasing the suction pressure only increases the rate of
evaporation of water in the drainage system.
Level of Cognitive Ability - Application
Integrated Process - Nursing ProcessImplementation
Strategy:
Use the process of elimination and think about the physiology associated with each
chamber of the chest tube drainage system. Remember that continuous gentle
bubbling in the suction control chamber is expected. If you had difficulty with this
question, review nursing interventions for clients with chest tubes. Reference:
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1118-1121). St.
Louis: Mosby. page 1 Elsevier items and derived items 2008 by Saunders, an
imprint of Elsevier Inc.
Question:
A nurse has assisted a physician with the insertion of a chest tube. The nurse
monitors the client and notes fluctuation of the fluid level in the water seal chamber
after the tube is inserted. Based on this assessment, which action would be
appropriate?
Options:
1. Inform the physician.
2. Continue to monitor the client.
3. Reinforce the occlusive dressing.
4. Encourage the client to deep-breathe.
Answer:
2.
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 a
dependent loop exists, if the suction is not working properly, or if the lung has
reexpanded. Options 1, 3, and 4 are incorrect.
Level of Cognitive Ability - Analysis

Strategy:
Use the process of elimination and focus on the subject, fluctuation of the fluid level
in the water seal chamber. Recalling that this is an expected finding will direct you
to the correct option. Review the expected and unexpected assessment findings in
the care of a client with a chest tube if you had difficulty with this question.
Reference:
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p. 1118). St. Louis:
Mosby. page 1 Elsevier items and derived items 2008 by Saunders, an imprint of
Elsevier Inc.
Question:
A nurse caring for a client with a chest tube turns the client to the side, and the
chest tube accidentally disconnects. The initial nursing action is to:
Options:
1. Call the physician.
2. Place the tube in a bottle of sterile water.
3. Immediately replace the chest tube system.
4. Place a sterile dressing over the disconnection site.
Answer:
2.
Rationale:
If the chest drainage system is disconnected, the end of the tube is placed in a
bottle of sterile water held below the level of the chest. The system is replaced if it
breaks or cracks or if the collection chamber is full. Placing a sterile dressing over
the disconnection site will not prevent complications resulting from the
disconnection. The physician may need to be notified, but this is not the initial
action. Level of Cognitive Ability - Application
Strategy:
Use the process of elimination and note the strategic word initial in the question.
This indicates that a nursing action is required that will prevent a serious
complication as a result of the disconnection. Eliminate options 1 and 3 because
these actions delay required and immediate intervention. From the remaining
options, recalling the complications that can occur from a disconnection will direct
you to option 2. Review interventions related to the complications of a chest tube if
you had difficulty with this question.
Reference:
Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., p. 874). St.
Louis: Mosby. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., p.
1119). St. Louis: Mosby. page 1 Elsevier items and derived items 2008 by
Saunders, an imprint of Elsevier Inc.
Question:
A nurse is assisting a physician with the removal of a chest tube. The nurse should
instruct the client to: Options:
1. Exhale slowly.
2. Stay very still.
3. Inhale and exhale quickly.
4. Perform the Valsalva maneuver.
Answer:
4.
Rationale:
When the chest tube is removed, the client is asked to perform the Valsalva
maneuver (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.
Strategy:
Use the process of elimination and focus on the subject. Visualize the procedure and
the client instructions as you select an option. If you had difficulty with this
question, review the procedure for removal of a chest tube.
Reference:
Perry, A., & Potter, P. (2006). Clinical nursing skills & techniques (6th ed., pp. 869870). St. Louis: Mosby.
Inc.
Question:
While changing the tapes on a tracheostomy tube, the client coughs and the tube is
dislodged. The initial nursing action is to:
Options:
1. Call the physician to reinsert the tube.
2. Grasp the retention sutures to spread the opening.
3. Call the respiratory therapy department to reinsert the tracheotomy.
4. Cover the tracheostomy site with a sterile dressing to prevent infection.
Answer:
2.
Rationale:
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 1 and 3 will delay treatment in this emergency situation.
Strategy:
Use the process of elimination. Eliminate options 1 and 3 first because they are
comparative or alike and will delay the immediate intervention needed. Eliminate
option 4 because this action will block the airway. If you had difficulty with this
question, review the intervention required if a tracheostomy tube dislodges.
Reference:
Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing:
Assessment and management of clinical problems (6th ed., p. 582). St. Louis:
Mosby.
Inc.
Question:
A nurse 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?
Options:
1. Stridor
2. Occasional pink-tinged sputum
3. A few basilar lung crackles on the right
4. Respiratory rate of 24 breaths/min
Answer:
1.
Rationale:
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 2, 3, and 4 are
not signs that require immediate notification of the physician. Level of Cognitive
Ability - Analysis
Strategy:
Use the process of elimination. Recall that the prime danger after removal of an
artificial airway is the client s ability to maintain a patent airway and breathe
independently. In comparing each of the options with this risk in mind, eliminate
options 2, 3, and 4. Because stridor indicates laryngeal edema and possible airway
obstruction, it is the symptom that must be reported immediately. Review care to
the client following removal of an endotracheal tube if you had difficulty with this
question.
Reference:
Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking
for collaborative care (5th ed., p. 669). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse is assessing the functioning of a chest tube drainage system in a client who
has just returned from the recovery room following a thoracotomy with wedge
resection. Select all expected assessment findings.
Options:
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. Drainage system maintained below the client s chest
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation Answer:
3.4.5.6.
Rationale:
The bubbling of water in the water seal chamber indicates air drainage from the
client and usually is seen when intrathoracic pressure is higher than atmospheric
pressure, and may occur during exhalation, coughing, or sneezing. Excessive
bubbling in the water seal chamber may indicate an air leak, an unexpected finding.
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 or that the lung has reexpanded and that 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. Drainage that is more that 100 mL/hr is
considered excessive and requires physician 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.
Integrated Process - Nursing ProcessAssessment

Strategy:
Thinking about the physiology associated with the functioning of a chest tube
drainage system will assist in answering this question. The words excessive
bubbling and vigorous bubbling will assist in eliminating these assessment findings.
Review care for the client with a chest tube drainage system if you had difficulty
with this question.
Reference:
for collaborative care (5th ed., pp. 623-625). Philadelphia: W.B. Saunders.
Question:
An emergency room nurse is assessing a 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?
Options:
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at the site of injury
Answer:
2.
Rationale:
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.
Strategy:
Use the process of elimination and note the strategic word blunt in the question.
This will assist in eliminating option 4, sucking chest wound injury. Knowing that in a
respiratory injury increased respirations will occur will assist you in eliminating
option 1. Option 3 can be eliminated because a barrel chest is a characteristic
finding in a client with chronic obstructive pulmonary disease. Review the signs of
pneumothorax if you had difficulty with this question.
Reference:

Inc.
Question:
A nurse 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? Options:
1. Hypocapnia
2. A hyperinflated chest noted on the chest x-ray
3. Increased oxygen saturation with exercise
4. A widened diaphragm noted on the chest x-ray
Answer:
2.
Rationale:
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.
Strategy:
Use the process of elimination. Eliminate option 1 because in the client with COPD,
hypercapnia would be noted. Next, eliminate option 3 because oxygen desaturation
rather than saturation would occur. From the remaining options, reading carefully
will assist in directing you to option 2. If you are unfamiliar with the manifestations
associated with COPD, review this content.
Reference:
Inc.
Question:
An oxygen delivery system is prescribed for a 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?
Options:
1. Face tent
2. Venturi mask
3. Aerosol mask
4. Tracheostomy collar
Answer:
2.
Rationale:
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.
Integrated Process - Nursing ProcessAnalysis
Strategy:
Use the process of elimination and note the strategic words precise oxygen
concentration . Eliminate options 1, 3, and 4 because they are comparative or alike
in that they are used to provide high humidity. Review the various types of oxygen
delivery systems if you had difficulty with this question. Reference:
Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., pp. 766768). St. Louis: Mosby.
Inc.
Question:
A nurse is instructing a hospitalized client with a diagnosis of emphysema about
measures that will enhance the effectiveness of breathing during dyspneic periods.
Which of the following positions will the nurse instruct the client to assume?
Options:
1. Sitting up in bed
2. Side-lying in bed
3. Sitting in a recliner chair
4. Sitting on the side of the bed and leaning on an overbed table
Answer:
4.
Rationale:
Positions that will assist the client with emphysema with breathing include sitting up
and leaning on an overbed table, sitting up and resting the elbows on the knees,
and standing and leaning against the wall. Level of Cognitive Ability - Application

Strategy:
comparative or alike. Next, eliminate option 2 because this position will not enhance
breathing. If you had difficulty with this question, review the positions that will
decrease the work of breathing in a client with emphysema. Reference:
Mosby.
Inc.
Question:
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: Options:
1. Dyspnea
2. Chest pain
3. A bloody, productive cough
4. A cough with the expectoration of mucoid sputum
Answer:
4.
Rationale:
One of the first pulmonary symptoms is a slight cough with the expectoration of
mucoid sputum. Options 1, 2, and 3 are late symptoms and signify cavitation and
extensive lung involvement.
Strategy:
Use the process of elimination and note the strategic word first in the question. This
should direct you easily to option 4. If you are unfamiliar with the signs associated
with tuberculosis, review this content. Reference:
Inc.
Question:
A nurse performs an admission assessment on a client with a diagnosis of
tuberculosis. The nurse reviews the results of which diagnostic test that will confirm
this diagnosis?
Options:
1. Bronchoscopy
2. Sputum culture
3. Chest x-ray
4. Tuberculin skin test
Answer:
2.
Rationale:
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. Level of
Cognitive Ability - Analysis
Strategy:
Note the strategic word confirm in the question. Confirmation is made by identifying
M. tuberculosis. If you had difficulty with this question, review the diagnostic
procedures related to tuberculosis. Reference:
Inc.
Question:
A nursing instructor asks a nursing student to describe the route of transmission of
tuberculosis. The instructor concludes that the student understands this information
if the student states that tuberculosis is transmitted by:
Options:
1. Hand to mouth
2. The airborne route
3. The fecal-oral route
4. Blood and body fluids
Answer:
2.
Rationale:
Tuberculosis is an infectious disease caused by the bacillus Mycobacterium
tuberculosis and is spread primarily by the airborne route. Options 1, 3, and 4 are
incorrect.
Client Needs - Safe and Effective Care Environment
Strategy:
Focus on the disorder. Recalling that tuberculosis is a respiratory disease will direct
you easily to option 2. If you had difficulty with this question, review the
transmission of this disease.
Reference:
Inc.
Question:
A nurse is caring for a client with emphysema who is receiving oxygen. The nurse
assesses the oxygen flow rate to ensure that it does not exceed:
Options:
1. 1 L/min
2. 2 L/min
3. 6 L/min
4. 10 L/min
Answer:
2.
Rationale:
Oxygen is used cautiously and should not exceed 2 L/min. Because of the longstanding 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.
Strategy:
Use the process of elimination, focusing on the client s diagnosis. Recalling that in
the client with emphysema, respiratory drive is triggered by low oxygen levels will
direct you to option 2. If you are unfamiliar with this important concept, review this
content.
Reference:
Inc.
Question:
Which of the following arterial blood gas results indicates metabolic alkalosis?
Options:
1. pH of 7.34, PCO2 of 50 mm Hg, HCO3 of 32 mEq/L, PO2 of 70 mm Hg
Answer:
4.
Rationale:
In a metabolic alkalosis, the pH is elevated, along with the bicarbonate level
(HCO3). Option 4 is the only option that reflects these values.
Strategy:
Remember that when an alkalotic condition exists, the pH will be elevated. This will
assist in eliminating options 1 and 3. Next, recall that in a metabolic condition, the
HCO3 will move in the same direction as the pH. The only option that represents
these conditions is option 4. Review the process of blood gas analysis if you had
difficulty with this question.
Reference:
Inc.
Question:
Which of the following arterial blood gas results indicates metabolic alkalosis?
Options:
Answer:
4.
Rationale:
In a metabolic alkalosis, the pH is elevated, along with the bicarbonate level
(HCO3). Option 4 is the only option that reflects these values.

Strategy:
Remember that when an alkalotic condition exists, the pH will be elevated. This will
assist in eliminating options 1 and 3. Next, recall that in a metabolic condition, the
HCO3 will move in the same direction as the pH. The only option that represents
these conditions is option 4. Review the process of blood gas analysis if you had
Reference:
Inc.
Question:
A nurse instructs a 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:
Options:
1. Promote oxygen intake.
2. Strengthen the diaphragm.
3. Strengthen the intercostal muscles.
4. Promote carbon dioxide elimination.
Answer:
4.
Rationale:
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 1, 2, and 3 are not
the purposes of this type of breathing.
Strategy:
Visualize the use of this procedure to assist you in answering correctly. Knowledge
regarding the respiratory conditions in which this type of breathing is helpful also
will assist in directing you to option 4. Review the purpose of this breathing
technique, if you had difficulty with this question.
Reference:
Assessment and management of clinical problems (6th ed., pp. 557, 672). St. Louis:
Mosby.
Elsevier Inc.
Question:
A nurse reviews the arterial blood gas values and notes a pH of 7.50, a Pco2 of 30
mm Hg, and an HCO3 of 25 mEq/L. The nurse interprets these values as indicating:
Options:
1. Metabolic acidosis, uncompensated
2. Respiratory acidosis, uncompensated
3. Respiratory alkalosis, uncompensated
4. Metabolic acidosis, partially compensated
Answer:
3.
Rationale:
In respiratory alkalosis, the pH will be higher than normal and the Pco2 will be low.
The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. The only option
that reflects these conditions is option 3.
Strategy:
Remember that when an alkalotic condition exists, the pH will be high. Next, recall
that in a respiratory alkalotic condition, the Pco2 will move in the opposite direction
from the pH. The only option that represents these conditions is option 3.
Compensation can be identified if the pH is within normal limits. Review the process
of blood gas analysis if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is caring for a client with acute respiratory distress syndrome. Which of the
following would the nurse expect to note in the client?
Options:
1. Pallor
2. Low arterial PaO2

3. Elevated arterial PaO2
4. Decreased respiratory rate
Answer:
2.
Rationale:
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.
Strategy:
Use the process of elimination. Note that options 2 and 3 relate to the same subject
but present opposite conditions. This may provide you with the clue that one of
these options is correct. Considering the diagnosis of the client, the best choice is
option 2. Review the clinical manifestations associated with acute respiratory
distress syndrome if you had difficulty with this question.
Reference:
for collaborative care (5th ed., pp. 655, 2183). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse is preparing to obtain a sputum specimen from a client. Which of the
following nursing actions will facilitate obtaining the specimen?
Options:
1. Limiting fluids
2. Having the client take three deep breaths
3. Asking the client to spit into the collection container
4. Asking the client to obtain the specimen after eating
Answer:
2.
Rationale:
To obtain a sputum specimen, the client should rinse the mouth to reduce
contamination, breathe deeply, and then cough into a sputum specimen container.
The client should be encouraged to cough and not spit so as to obtain sputum.
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.

Strategy:
Use the process of elimination. Option 1 can be eliminated first because general
principles indicate that fluids assist in loosening or thinning secretions. Eliminate
option 3 because of the word spit . Spit is different from sputum. Next, eliminate
option 4 because of the words after eating . Review this procedure if you had
Reference:
ed., pp. 1018- 1019). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse is caring for a client after a bronchoscopy and biopsy. Which of the following
signs, if noted in the client, should be reported immediately to the physician?
Options:
1. Dry cough
2. Hematuria
3. Bronchospasm
4. Blood-streaked sputum
Answer:
3.
Rationale:
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is
expected for several hours. Frank blood indicates hemorrhage. A dry cough may be
expected. The client should be assessed for signs of complications, which would
include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension,
tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
Strategy:
Use the process of elimination. Eliminate option 2 first because it is unrelated to the
procedure. Next, eliminate option 1 because a dry cough may be expected. Noting
that a biopsy has been performed will assist in eliminating option 4, because bloodstreaked sputum would be expected. Note that option 3, the correct option, relates
to the airway. If you had difficulty with this question, review postprocedure care
following bronchoscopy with biopsy.
Reference:
Inc.
Question:
A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning,
the nurse must limit the suctioning time to a maximum of:
Options:
1. 1 minute
2. 5 seconds
3. 10 seconds
4. 30 seconds
Answer:
3.
Rationale:
Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker
cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse
must preoxygenate the client before suctioning and limit the suctioning pass to 10
seconds.
Strategy:
Use the process of elimination. Recall that during suctioning, the client s airway is
blocked; therefore, you should be able to eliminate options 1 and 4 easily. From the
remaining options, eliminate option 2 because of the short time frame. Five seconds
does not seem reasonable to achieve removal of secretions. Review the procedure
for suctioning if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A nurse is suctioning fluids from a client through an endotracheal tube. During the
suctioning procedure, the nurse notes on the monitor that the heart rate is
decreasing. Which of the following is the appropriate nursing intervention?
Options:
1. Continue to suction.
2. Notify the physician immediately.
3. Stop the procedure and reoxygenate the client.
4. Ensure that the suction is limited to 15 seconds.
Answer:
3.
Rationale:
During suctioning, the nurse should monitor the client closely for side effects,
including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting
from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If
side effects develop, especially cardiac irregularities, the procedure is stopped and
the client is reoxygenated.
Strategy:
Use the process of elimination, recalling that suctioning can cause cardiac
irregularities. Noting the strategic words heart rate is decreasing should direct you
to option 3. If you had difficulty with this question, review the complications and
interventions associated with suctioning procedures. Reference:
Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for
positive outcomes (7th ed., pp. 1888, 1890). Philadelphia: W.B. Saunders.
Mosby.
Inc.
Question:
An unconscious client is admitted to an emergency room. Arterial blood gas
measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide
level, a normal oxygen level, and an elevated potassium level. These results
indicate the presence of:
Options:
1. Metabolic acidosis
2. Respiratory acidosis
3. Overcompensated respiratory acidosis
4. Combined respiratory and metabolic acidosis
Answer:
1.
Rationale:
In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a
low bicarbonate level along with the low pH would indicate a metabolic state.
Therefore, options 2, 3, and 4 are incorrect. Level of Cognitive Ability - Analysis
Strategy:
Use the Pyramid Steps for evaluating the results of a blood gas test. Remember to
look at the pH first. This pH of 7.30 would indicate an acidosis. Next, look at the CO2
level, which in this situation is normal; therefore, a respiratory condition does not
exist. This will assist you in eliminating options 2, 3, and 4. Noting that the
bicarbonate level is low, as is the pH, should assist in directing you to option 1, a
metabolic condition. Review blood gas analysis if you had difficulty with this
question.
Reference:
Inc.
Question:
An unconscious client is admitted to an emergency room. Arterial blood gas
measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide
level, a normal oxygen level, and an elevated potassium level. These results
indicate the presence of:
Options:
3. Overcompensated respiratory acidosis
4. Combined respiratory and metabolic acidosis
Answer:
1.
Rationale:
In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a
low bicarbonate level along with the low pH would indicate a metabolic state.
Therefore, options 2, 3, and 4 are incorrect. Level of Cognitive Ability - Analysis
Strategy:
Use the Pyramid Steps for evaluating the results of a blood gas test. Remember to
look at the pH first. This pH of 7.30 would indicate an acidosis. Next, look at the CO2
level, which in this situation is normal; therefore, a respiratory condition does not
exist. This will assist you in eliminating options 2, 3, and 4. Noting that the
bicarbonate level is low, as is the pH, should assist in directing you to option 1, a
metabolic condition. Review blood gas analysis if you had difficulty with this
question.
Reference:
Inc.
Question:
A client is suspected of having a pulmonary embolus. A nurse assesses the client,
knowing that which of the following is a common clinical manifestation of pulmonary
embolism?
Options:
1. Dyspnea
2. Bradypnea
3. Bradycardia
4. Decreased respirations
Answer:
1.
Rationale:
The common clinical manifestations of pulmonary embolism are tachypnea,
tachycardia, dyspnea, and chest pain.
Strategy:
Use the process of elimination. Eliminate options 2, 3, and 4 because they are
comparative or alike. Review the clinical manifestations of pulmonary embolism if
you had difficulty with this question. Reference:
Inc.
Question:
A nurse teaches a client about the use of a respiratory inhaler. Which action by the
client indicates a need for further teaching?
Options:
1. Inhales the mist and quickly exhales
2. Removes the cap and shakes the inhaler well before use
3. Presses the canister down with the finger as he breathes in
4. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
Answer:
1.
Rationale:
The client should be instructed to hold his or her breath for at least 10 to 15
seconds before exhaling the mist. Options 2, 3, and 4 are accurate instructions
regarding the use of the inhaler.
Strategy:
Use the process of elimination, noting the strategic words need for further teaching
. These words indicate a negative event query and ask you to select an option that
is incorrect. Visualize this procedure to answer the question. If you are unfamiliar
with the client teaching points related to the use of an inhaler, review this
procedure.
Reference:
Question:
A client has just returned to a nursing unit following bronchoscopy. A nurse would
implement which of the following nursing interventions for this client?
Options:
1. Administering atropine intravenously
2. Administering small doses of midazolam (Versed)
3. Encouraging additional fluids for the next 24 hours
4. Ensuring the return of the gag reflex before offering food or fluids
Answer:
4.
Rationale:
After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex
returns because the preoperative sedation and local anesthesia impair swallowing
and the protective laryngeal reflexes for a number of hours. Additional fluids are
unnecessary because no contrast dye is used that would need flushing from the
system. Atropine and midazolam would be administered before the procedure, not
after.
Strategy:
Use the process of elimination. Recall that the client has lost the protective cough,
gag, and swallow reflexes during this procedure. Knowledge of this implication helps
you choose option 4 as the only possible answer. Review nursing care measures
following a bronchoscopy if you had difficulty with this question.
Reference:
Inc.
Question:
A client has an order to have radial arterial blood gases drawn. Before drawing the
sample, a nurse occludes the:
Options:
1. Ulnar artery and observes for color changes in the affected hand
2. Radial artery and observes for color changes in the affected hand
3. Brachial and radial arteries, releases them, and then observes the circulation to
the hand 4. Radial and ulnar arteries, releases one, evaluates the color of the hand,
and repeats the process with the other artery
Answer:
4.
Rationale:
Before drawing a sample for arterial blood gas analysis, the nurse assesses the
collateral circulation to the hand with Allen s test. This involves compressing the
radial and ulnar arteries and asking the client to close and open the fist, which
should cause the hand to become pale. The nurse then releases pressure on one
artery and observes whether circulation is restored quickly. The nurse repeats the
process, releasing the other artery. The blood sample may be taken safely if
collateral circulation is adequate.
Strategy:
Use the process of elimination, recalling that the nurse must ensure collateral
circulation to the hand before drawing a sample for arterial blood gas testing.
Consider the anatomy of the blood vessels that lead to the hand to direct you to
option 4. If you are unfamiliar with Allen s test, review this procedure. Reference:
ed., pp. 248-249). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse is assessing the respiratory status of a client who has suffered a fractured
rib. The nurse would expect to note which of the following?
Options:
1. Slow deep respirations
2. Rapid deep respirations
3. Paradoxical respirations
4. Pain, especially with inspiration
Answer:
4.
Rationale:
Rib fractures are a common injury, especially in the older client, and result from a
blunt injury or a fall. Typical signs and symptoms include pain and tenderness
localized at the fracture site and exacerbated by inspiration and palpation, shallow
respirations, splinting or guarding the chest protectively to minimize chest
movement, and possible bruising at the fracture site. Paradoxical respirations are
seen with flail chest.
Strategy:
Use the process of elimination. Focusing on the anatomical location of the injury will
direct you to option 4. Review the assessment findings in rib fractures if you had
Reference:
positive outcomes (7th ed., p. 1901). Philadelphia: W.B. Saunders.
Inc.
Question:
A client with chest injury has suffered flail chest. A nurse assesses the client for
which most distinctive sign of flail chest?
Options:
1. Cyanosis
2. Hypotension
3. Paradoxical chest movement
4. Dyspnea, especially on exhalation
Answer:
3.
Rationale:
Flail chest results from fracture of two or more ribs in at least two places each. This
results in a floating section of ribs. Because this section is unattached to the rest
of the bony rib cage, this segment results in paradoxical chest movement. This
means that the force of inspiration pulls the fractured segment inward, while the
rest of the chest expands. Similarly, during exhalation, the segment balloons
outward while the rest of the chest moves inward. This is a telltale sign of flail chest.
Strategy:
Use the process of elimination, focusing on the strategic words most distinctive .
Cyanosis and hypotension occur with many different disorders, so eliminate options
1 and 2 first. From the remaining options, choose paradoxical chest movement over
dyspnea on exhalation by remembering that a flail chest has broken rib segments
that move independently of the rest of the rib cage. Review the assessment findings
in flail chest if you had difficulty with this question.
Reference:
positive outcomes (7th ed., p. 1901-1902). Philadelphia: W.B. Saunders.
Inc.
Question:
A client has been admitted with chest trauma after a motor vehicle accident and
has undergone subsequent intubation. A nurse checks the client when the highpressure alarm on the ventilator sounds, and notes that the client has absence of
breath sounds in the right upper lobe of the lung. The nurse immediately assesses
for other signs of:
Options:
1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome

Answer:
1.
Rationale:
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds
on the affected side. Pneumothorax can cause increased airway pressure because
of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary
embolism are not characterized by absent breath sounds. An endotracheal tube that
is inserted too far can cause absent breath sounds, but the lack of breath sounds
most likely would be on the left side because of the degree of curvature of the right
and left main stem bronchi.
Strategy:
Use the process of elimination. Focus on the symptoms presented in the question
and note the relationship between right upper lobe and right pneumothorax in
option 1. Review the manifestations associated with pneumothorax if you had
Reference:
Assessment and management of clinical problems (6th ed., pp. 621-622). St. Louis:
Mosby.
Inc.
Question:
A client with no history of respiratory disease is admitted with respiratory failure. A
nurse assesses the arterial blood gas report for which of the following results that
are consistent with this disorder? Options:
1. PaO2 58 mm Hg, PaCO2 32 mm Hg
Answer:
3.
Rationale:
Respiratory failure is described as a PaO2 of 60 mm Hg or lower and a PaCO2 of 50
mm Hg or higher in a client with no history of respiratory disease. In a client with a
history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more

(PaCO2) from the client s baseline are considered diagnostic.
Strategy:
Use the process of elimination. Focusing on the client s diagnosis will direct you to
option 3, the option with the lowest PaO2 level. Review the blood gas findings in a
client with respiratory failure if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is teaching a client with chronic respiratory failure how to use a metereddose inhaler correctly. The nurse instructs the client to:
Options:
1. Inhale quickly.
2. Inhale through the nose.
3. Hold the breath after inhalation.
4. Take two inhalations during one breath.
Answer:
3.
Rationale:
Instructions for using a metered-dose inhaler include shaking the canister, holding it
right side up, inhaling slowly and evenly through the mouth, delivering one spray
per breath, and holding the breath after inhalation.
Strategy:
This question tests a fundamental concept of medication administration using
inhalers. Visualize the procedure and use the process of elimination to direct you to
option 3. If you selected the incorrect option, review the key principles of this
medication therapy.
Reference:
Inc.
Question:
A nurse is assessing a client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse assesses for which earliest sign of acute
respiratory distress syndrome? Options:
1. Bilateral wheezing
2. Inspiratory crackles
3. Intercostal retractions
4. Increased respiratory rate
Answer:
4.
Rationale:
The earliest detectable sign of acute respiratory distress syndrome is an increased
respiratory rate, which can begin from 1 to 96 hours after the initial insult to the
body. This is followed by increasing dyspnea, air hunger, retraction of accessory
muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory
crackles or diffuse coarse crackles.
Strategy:
Use the process of elimination, noting the strategic word earliest . Eliminate option
3 first because intercostal retraction is a later sign of respiratory distress. Of the
remaining options, recall that adventitious breath sounds (options 1 and 2) would
occur later than an increased respiratory rate. Review the early signs of acute
respiratory distress syndrome if you had difficulty with this question. Reference:
Assessment and management of clinical problems (6th ed., pp. 1839-1840). St.
Louis: Mosby.
Inc.
Question:
A nurse is taking pulmonary artery catheter measurements of a client with acute
respiratory distress syndrome. The pulmonary capillary wedge pressure reading is
12 mm Hg. The nurse interprets that this reading is:
Options:
1. High and expected
2. Low and unexpected
3. Normal and expected
4. Uncertain and unexpected

Answer:
3.
Rationale:
The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the
client is considered to have high readings if they exceed 18 to 20 mm Hg. The client
with acute respiratory distress syndrome has a normal PCWP, which is an expected
finding because the edema is in the interstitium of the lung and is noncardiac.
Strategy:
To answer this question correctly, you must know that the PCWP is normal. This
makes sense if you know that in acute respiratory distress syndrome, fluid
accumulates in the interstitium of the lung and not in the vascular bed. Learn the
normal PCWP reading if you are unfamiliar with it.
Reference:
Inc.
Question:
A nurse is assessing a client with chronic airflow limitation and notes that the client
has a barrel chest. The nurse interprets that this client has which of the following
forms of chronic airflow limitation? Options:
1. Emphysema
2. Bronchial asthma
3. Chronic obstructive bronchitis
4. Bronchial asthma and bronchitis
Answer:
1.
Rationale:
The client with emphysema has hyperinflation of the alveoli and flattening of the
diaphragm. These lead to increased anteroposterior diameter, referred to as barrel
chest. The client also has dyspnea with prolonged expiration and has
hyperresonant lungs to percussion.
Strategy:
Use the process of elimination. Recall that the barrel chest is a result of long-term
hyperinflation of the lungs and air trapping. Knowing that emphysema is the only
type of chronic airflow limitation in which this occurs will enable you to eliminate
each of the other, incorrect options. Review the characteristics of emphysema if you
had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A nurse is caring for a client diagnosed with tuberculosis. Which assessment, if
made by the nurse, is inconsistent with the usual clinical presentation of
tuberculosis and may indicate the development of a concurrent problem?
Options:
1. Cough
2. High-grade fever
3. Chills and night sweats
4. Anorexia and weight loss
Answer:
2.
Rationale:
The client with tuberculosis usually experiences cough (productive or
nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest
discomfort or pain, chills and sweats (which may occur at night), and a low-grade
fever.
Strategy:
symptoms that are common in the client with tuberculosis. From the remaining
options, you need to know that the client may get night sweats or that the fever is
low grade. Review the clinical manifestations associated with tuberculosis if you had
Reference:
Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., p. 774).
St. Louis: Mosby. page 1 Elsevier items and derived items 2008 by Saunders, an

Question:
A nurse is teaching a client with tuberculosis about dietary elements that should be
increased in the diet. The nurse suggests that the client increase intake of:
Options:
1. Potatoes and fish
2. Eggs and spinach
3. Grains and broccoli
4. Meats and citrus fruits
Answer:
4.
Rationale:
The nurse teaches the client with tuberculosis to increase intake of protein, iron,
and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons,
pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale,
asparagus, and turnip greens. Food sources that are rich in iron include liver and
other meats. Less than 10% of iron is absorbed from eggs, and less than 5% is
absorbed from grains and vegetables.
Strategy:
Use the process of elimination. Recall that the diet in tuberculosis should be high in
protein, vitamin C, and iron. Knowing which types of foods contain these various
nutrients will direct you to option 4. If you had difficulty with this question, review
these nutritional concepts.
Reference:
Inc.
Question:
A nurse has conducted discharge teaching with a client diagnosed with tuberculosis.
The client has been taking medication for 1 weeks. The nurse evaluates that the
client has understood the information if the client makes which of the following
statements?
Options:
1. I need to continue drug therapy for 2 months.
2. I can t shop at the mall for the next 6 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.
Answer:
4.
Rationale:
The client is continued on medication therapy for 6 to 12 months, depending on the
situation. The client generally is considered not to be 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 work when the results of three sputum cultures are
negative.
Integrated Process - Nursing ProcessEvaluation
Strategy:
Use the process of elimination. Knowing that the medication therapy lasts for at
least 6 months helps you eliminate option 1 first. Knowing that three sputum
cultures must be negative helps you to eliminate option 3 next. From the remaining
options, recalling that the client is not contagious after 2 to 3 weeks of therapy will
direct you to option 4. If you had difficulty with this question, review the infectious
period of tuberculosis.
Reference:
positive outcomes (7th ed., pp. 1847-1848). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse is preparing to give a bed bath to an immobilized client with tuberculosis.
The nurse should wear which of the following items when performing this care?
Options:
1. Surgical mask and gloves
2. Particulate respirator, gown, and gloves
3. Particulate respirator and protective eyewear
4. Surgical mask, gown, and protective eyewear
Answer:
2.
Rationale:
The nurse who is in contact with a client with tuberculosis should wear an
individually fitted particulate respirator. The nurse also would wear gloves as per
standard precautions. The nurse wears a gown when the possibility exists that the
clothing could become contaminated, such as when giving a bed bath.
Strategy:
Use the process of elimination. Knowing that the nurse should wear a particulate
respirator eliminates options 1 and 4. Knowledge of basic standard precautions
directs you to option 2 from the remaining options. Review precautions related to
the care of a client with tuberculosis if you had difficulty with this question.
Reference:
Inc.
Question:
A client has experienced pulmonary embolism. A nurse assesses for which
symptom, which is most commonly reported?
Options:
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken
Answer:
3.
Rationale:
The most common initial symptom in pulmonary embolism is chest pain that is
sudden in onset. The next most commonly reported symptom is dyspnea, which is
accompanied by an increased respiratory rate. Other typical symptoms of
pulmonary embolism include tachycardia, fever, diaphoresis, cough, anxiety, and
possibly syncope.
Strategy:
Use the process of elimination. Because pulmonary embolism does not result from
an infectious process or an allergic reaction, eliminate options 1 and 2 first. To select
between options 3 and 4, look at them closely. Option 4 states dyspnea when deep
breaths are taken. Although dyspnea commonly occurs with pulmonary embolism,
dyspnea is not associated only with deep breathing. Therefore, eliminate option 4.
Review the signs of pulmonary embolism if you had difficulty with this question.
Reference:
Inc.
Question:
A client has experienced pulmonary embolism. A nurse assesses for which
symptom, which is most commonly reported?
Options:
1. Hot, flushed feeling
2. Sudden chills and fever
3. Chest pain that occurs suddenly
4. Dyspnea when deep breaths are taken
Answer:
3.
Rationale:
The most common initial symptom in pulmonary embolism is chest pain that is
sudden in onset. The next most commonly reported symptom is dyspnea, which is
accompanied by an increased respiratory rate. Other typical symptoms of
pulmonary embolism include tachycardia, fever, diaphoresis, cough, anxiety, and
possibly syncope.
Strategy:
Use the process of elimination. Because pulmonary embolism does not result from
an infectious process or an allergic reaction, eliminate options 1 and 2 first. To select
between options 3 and 4, look at them closely. Option 4 states dyspnea when deep
breaths are taken. Although dyspnea commonly occurs with pulmonary embolism,
dyspnea is not associated only with deep breathing. Therefore, eliminate option 4.
Review the signs of pulmonary embolism if you had difficulty with this question.
Reference:
Inc.
Question:
A client experiencing confusion and tremors is admitted to a nursing unit. An initial
arterial blood gas report indicates that the PaCO2 level is 72 mm Hg, whereas the
PaO2 level is 64 mm Hg. A nurse interprets that the client is most likely
experiencing:
Options:
2. Respiratory alkalosis
3. Carbon dioxide narcosis
4. Carbon monoxide poisoning
Answer:
3.
Rationale:
Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with
carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such
as confusion and tremors, which may progress to convulsions and possibly coma.
Strategy:
Use the process of elimination, focusing on the data in the question. Noting that the
carbon dioxide (CO2) level is elevated will direct you to the correct option, CO2
narcosis. Review the clinical manifestations associated with CO2 narcosis if you had
Reference:
Assessment and management of clinical problems (6th ed., pp. 669, 1833). St.
Louis: Mosby.
Inc.
Question:
A client who is human immunodeficiency viruspositive has had a Mantoux skin test.
The nurse notes a 7-mm area of induration at the site of the skin test. The nurse
interprets the results as:
Options:
1. Positive
2. Negative
3. Inconclusive
4. Indicating the need for repeat testing
Answer:
1.
Rationale:
The client with human immunodeficiency virus (HIV) infection is considered to have
positive results on Mantoux skin testing with an area larger than 5 mm of
induration. The client without HIV is positive with an induration larger than 10 mm.
The client with HIV is immunosuppressed, making a smaller area of induration
positive for this type of client. It is possible for the client infected with HIV to have
false- negative readings because of the immunosuppression factor. Options 2, 3,
and 4 are incorrect interpretations.
Strategy:
comparative or alike. From the remaining options, recalling that the client with HIV
is immunosuppressed will assist in determining the interpretation of the area of
induration. Review results of tuberculosis skin testing in an immunosuppressed
client if you had difficulty with this question.
Reference:
Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking
Inc.
Question:
A client with uncomplicated or simple silicosis is being monitored yearly at the
health care clinic. In this type of silicosis, the nurse expects that the client would:
Options:
1. Be asymptomatic
2. Complain of severe dyspnea
3. Experience malaise and fatigue
4. Experience anorexia and weight loss
Answer:
1.
Rationale:
In uncomplicated or simple silicosis, the client would be asymptomatic, although
evidence of fibrosis on an x-ray would be present. Malaise, anorexia, weight loss,
and severe dyspnea on exertion would occur in a client with chronic complicated
silicosis.
Strategy:
Use the process of elimination. Noting the words uncomplicated or simple will direct
you to option 1. Review the manifestations associated with silicosis if you had
Reference:
Mosby.
Inc.
Question:
A client with uncomplicated or simple silicosis is being monitored yearly at the
health care clinic. In this type of silicosis, the nurse expects that the client would:
Options:
1. Be asymptomatic
2. Complain of severe dyspnea
3. Experience malaise and fatigue
4. Experience anorexia and weight loss
Answer:
1.
Rationale:
In uncomplicated or simple silicosis, the client would be asymptomatic, although
evidence of fibrosis on an x-ray would be present. Malaise, anorexia, weight loss,
and severe dyspnea on exertion would occur in a client with chronic complicated
silicosis.
Strategy:
Use the process of elimination. Noting the words uncomplicated or simple will direct
you to option 1. Review the manifestations associated with silicosis if you had
Reference:
Mosby.
Inc.
Question:
A nurse is evaluating the respiratory status of a client with carbon dioxide narcosis
who is being ventilated mechanically. On evaluation of a set of arterial blood gases,
the nurse notes that the client s carbon dioxide level has dropped significantly. The
nurse then evaluates the client for which adverse effect of this rapid change?
Options:
1. Tachypnea
2. Confusion
3. Hyponatremia
4. Seizure activity
Answer:
4.
Rationale:
With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete
bicarbonate ions at the same rate. The client can experience rebound metabolic
alkalosis, with resulting seizure activity. The nurse evaluates the client s status
carefully during this period. Options 1, 2, and 3 are not adverse effects.
Strategy:
Use the process of elimination and knowledge regarding how the body maintains
acid-base balance. Because a rapid decline in the carbon dioxide level often results
in metabolic alkalosis, the client is at risk for seizure activity. Review the basic acidbase abnormalities and their manifestations if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse
assesses the client for which of the following signs and symptoms?
Options:
1. Dyspnea
2. Headache
3. Weight gain
4. Hypothermia
Answer:
1.
Rationale:
Histoplasmosis is an opportunistic fungal infection that can occur in the client with
acquired immunodeficiency syndrome (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. Enlargement of the client s lymph
nodes, liver, and spleen may occur as well.
Strategy:
Use the process of elimination. Recalling that histoplasmosis is an infectious process
will help you eliminate option 4. Because the client has AIDS and another infection,
weight gain is an unlikely symptom and can be eliminated next. Knowing that
histoplasmosis begins as a respiratory infection helps you choose dyspnea over
headache as the correct option. Review the signs of histoplasmosis if you had
Reference:
Inc.
Question:
A client has been admitted to a nursing unit with pulmonary sarcoidosis. A nurse
assesses the client for which of the following signs that indicates a complication of
the disorder?
Options:
1. Weak pulse
2. Weight loss
3. Distended neck veins
4. Bilateral lung crackles
Answer:
3.
Rationale:
Pulmonary sarcoidosis can lead to cor pulmonale (or failure of the right side of the
heart), characterized by distended neck veins, elevated central venous pressure,
full bounding pulse, weight gain, engorged liver, and peripheral edema. Bilateral
lung crackles would indicate failure of the left side of the heart. Level of Cognitive
Ability - Analysis
Strategy:
Recall that sarcoidosis is a restrictive lung disease. A complication of restrictive lung
disease is cor pulmonale because the right side of the heart has to work hard
continuously to overcome pulmonary resistance. Therefore, recalling the signs of
failure of the right side of the heart will direct you to option 3. Review the
complications of pulmonary sarcoidosis and the signs of failure of the right and left
sides of the heart if you had difficulty with this question.
Reference:
Question:
A nurse is caring for a client with exacerbation of sarcoidosis who is receiving
corticosteroids. A nurse teaches the client about adverse effects of medication
therapy, which would include:
Options:
1. Pruritus
2. Weight loss
3. Hyperkalemia
4. Hyperglycemia
Answer:
4.
Rationale:
The usual treatment for exacerbations of sarcoidosis includes systemic
corticosteroids. Side effects of this therapy include weight gain, changes in mood,
and hyperglycemia. Hyperkalemia and pruritus are unrelated findings.
Strategy:
Recall that sarcoidosis is a restrictive lung disease and that exacerbations are
treated with corticosteroids. Knowing that corticosteroids cause hyperglycemia will
direct you to the correct option. Review the medication therapy used in the
treatment of sarcoidosis if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The
nurse concludes that the client understands the information if the client reports
which of the following early signs of exacerbation?
Options:
1. Fever
2. Fatigue
3. Weight loss
4. Shortness of breath
Answer:
4.
Rationale:
Dry cough and dyspnea are typical signs and symptoms of pulmonary sarcoidosis.
Others include chest pain, hemoptysis, and pneumothorax. Systemic signs and
symptoms include weakness and fatigue, malaise, fever, and weight loss.
Strategy:
Use the process of elimination and note the strategic word early . Because
sarcoidosis is a pulmonary problem, eliminate options 1 and 3 first. Select option 4
over option 2 because the shortness of breath (and impaired ventilation) appears
first and would cause the fatigue as a secondary symptom. Review the early signs
of exacerbation in sarcoidosis if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is taking the history of a client with silicosis. The nurse assesses whether
the client wears which of the following items during periods of exposure to silica
particles?
Options:
1. Mask
2. Gown
3. Gloves
4. Eye protection
Answer:
1.
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. Options 2, 3, and 4 are
not necessary.
Strategy:
Use the process of elimination. Recalling that exposure to silica dust causes the
illness and that the dust is inhaled into the respiratory tract will direct you to option
1. If you had difficulty with this question, review the protective measures associated
with silicosis.
Reference:
Mosby.
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 795, 798-799).
Question:
A client tells a nurse that a physician has stated a diagnosis of uncomplicated or
simple silicosis and asks the nurse exactly what this means. In formulating a
response, the nurse incorporates the knowledge that:
Options:
1. There is evidence of silica in the bloodstream but no clinical symptoms.
2. The client has normal pulmonary function studies but has shortness of breath.
3. The client has mild ventilation restriction and has fibrosis on chest x-ray.
4. Massive pulmonary fibrosis is visible on chest x-ray, but no extrapulmonary
symptoms are apparent. Answer:
3.
Rationale:
The client with simple silicosis may be asymptomatic or have mild ventilatory
restriction and has evidence of fibrosis on chest x-ray. Pulmonary function studies
reveal some decreases in vital capacity and total lung volume. Massive fibrosis is
not evident at this stage. This disease is restricted to the respiratory system only.

Strategy:
Use the process of elimination. Option 4 has the least amount of fit with a disorder
that is described as simple or uncomplicated and therefore is eliminated first.
Because silicosis is a pulmonary disease, option 1 is eliminated. Option 2 is
incongruent; it would be difficult for a person to have shortness of breath and have
normal pulmonary function tests. Review the pathophysiology associated with
simple silicosis if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A nurse working on a medical respiratory nursing unit is caring for several clients
with respiratory disorders. The nurse would determine that which of the following
clients on the nursing unit is at the lowest risk for infection with tuberculosis?
Options:
1. An uninsured man who is homeless
2. A newly immigrated woman from Korea
3. A man who is an inspector for the U.S. Postal Service
4. An older woman admitted from a long-term care facility
Answer:
3.
Rationale:
Persons at high risk for acquiring tuberculosis include immigrants from Asia, Africa,
Latin America, and Oceania, medically underserved populations (ethnic minorities,
homeless), those with human immunodeficiency virus infection or other
immunosuppressive disorders, residents in group settings (long-term care,
correctional facilities), and health care workers.
Client Needs - Health Promotion and Maintenance
Strategy:
Use the process of elimination, noting the strategic words lowest risk . Begin to
answer this question by eliminating options 1 and 2 because immigrants and the
medically underserved more frequently are affected by the disease. From the
remaining options, the postal inspector may or may not come into contact with
many persons, depending on the job description. The client from the long-term care
facility, however, lives in a group setting where a large number of persons share a
common environment 24 hours a day. Review the risk factors associated with
tuberculosis if you had difficulty with this question. Reference:
Question:
A client has an order to receive purified protein derivative, 0.1 mL, intradermally. A
nurse administers the medication by using a tuberculin syringe with a:
Options:
1. 20-gauge, 1-inch needle inserted at a 30-degree angle, with the bevel side down
2. 26-gauge, -inch needle inserted at a 45-degree angle, with the bevel side down
3. 20-gauge, 1-inch needle inserted almost parallel to the skin, with the bevel side
up
4. 26-gauge, -inch needle inserted almost parallel to the skin, with the bevel side
up
Answer:
4.
Rationale:
A Mantoux skin test is administered by giving 0.1 mL of purified protein derivative
(PPD) intradermally. Administration involves drawing the medication into a
tuberculin syringe with a 25- to 27-gauge, -inch needle. The injection is given by
inserting the needle as close as possible to a parallel position with the skin and with
the needle bevel facing up. This results in formation of a wheal when the PPD is
administered correctly.
Strategy:
Remember that a tuberculin syringe is small and measures small amounts of
medication dosages. Use the process of elimination, eliminating options 1 and 3 first
because these options indicate the use of larger needles. Remembering that the
bevel side is up during administration of PPD will assist in directing you to the
correct option from the remaining choices. If this question was difficult, review the
basics of this injection technique.
Reference:
Inc.
Question:
A nurse is reading a Mantoux skin test for a client with no documented health
problems. The site has no induration and a 1-mm area of ecchymosis. The nurse
interprets that the result is:
Options:
1. Positive
2. Negative
3. Uncertain
4. Borderline
Answer:
2.
Rationale:
A positive reading has an induration measuring 10 mm or larger and is considered
abnormal. A small area of ecchymosis is insignificant and probably is related to
injection technique. Options 1, 3, and 4 are incorrect interpretations.
Strategy:
Recall that induration is necessary for a positive response. Because the client in this
question has no induration, the result can only be negative. Review Mantoux skin
test results if you had difficulty with this question.
Reference:
Question:
The nurse is preparing a list of home care instructions for the client who has been
hospitalized and treated for tuberculosis. Of the following instructions, which will the
nurse include on the list? Select all that apply.
Options:
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 already have
been exposed. 5. Cover the mouth and nose when coughing or sneezing and put
used tissues in plastic bags. 6. When one sputum culture is negative, the client is no
longer considered infectious and usually can return to former employment.
Answer:
1.3.4.5.
Rationale:
The nurse should provide the client and family with information about tuberculosis
and allay concerns about the contagious aspect of the infection. Instruct the client
to follow the medication regimen exactly as prescribed and always to have a supply
of the medication on hand. Advise the client of the side effects of the medication
and ways of minimizing them to ensure compliance. Reassure the client that after 2
to 3 weeks of medication therapy, it is unlikely that the client will infect anyone.
Inform the client that activities should be resumed gradually and about the need for
adequate nutrition and a well- balanced diet that is rich in iron, protein, and vitamin
C to promote healing and prevent recurrence of infection. Inform the client and
family that respiratory isolation is not necessary because family members already
have been exposed. Instruct the client about thorough hand washing and to cover
the mouth and nose when coughing or sneezing and to put used tissues into plastic
bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once
medication therapy is initiated. When the results of three sputum cultures are
negative, the client is no longer considered infectious and can usually return to
former employment.
Strategy:
Knowledge regarding the pathophysiology, transmission, and treatment of
tuberculosis is needed to answer this question. Read each option carefully to answer
correctly. Review home care instructions for the client with tuberculosis if you had
Reference:
Inc.
Question:
The nurse is teaching the client with emphysema about positions that help
breathing during dyspneic episodes. The nurse instructs the client to avoid which of
the following positions that will aggravate breathing?
Options:
1. Sitting up with the elbows resting on knees
2. Standing and leaning against a wall
3. Lying on the back in a low-Fowler s position
4. Sitting up and leaning on a table
Answer:
3.
Rationale:
The client should use the positions outlined in options 1, 2, and 4. These allow for
maximal chest expansion. The client should not lie on the back because it reduces
movement of a large area of the client s chest wall. Sitting is better than standing,
whenever possible. If no chair is available, then leaning against a wall while
standing allows accessory muscles to be used for breathing and not posture control.
Strategy:
Use the process of elimination, noting the strategic words dyspneic episodes and
avoid . Also, note that options 1, 2, and 4 are comparative or alike in that they all
address upright positions. If you had difficulty with this question, review client
teaching points related to emphysema.
Reference:
Inc.
Question:
The client is returned to the nursing unit following thoracic surgery with chest tubes
in place. During the first few hours postoperatively, the nurse assesses for drainage
and expects to note that it is: Options:
1. Serous
2. Serosanguineous
3. Bloody
4. Bloody, with frequent small clots
Answer:
3.
Rationale:
In the first few hours after surgery, the drainage from the chest tube is bloody. After
several hours, it becomes serosanguineous. The client should not experience
frequent clotting. Proper chest tube function should allow for drainage of blood
before it has the chance to clot in the chest or the tubing. Level of Cognitive
Ability - Analysis
Strategy:
Recall that following thoracic surgery, there may be considerable capillary oozing
for some hours in the postoperative period. This would lead you to choose the
bloody drainage over serous or
serosanguineous. Knowing that patent chest tubes do not allow blood to collect in
the pleural space eliminates the option of blood with clots. Review the assessment
measures required for the care of a client with a chest tube if you had difficulty with
this question.
Reference:
Inc.
Question:
The client has had radical neck dissection, and begins to hemorrhage at the incision
site. Which action by the nurse would be contraindicated?
Options:
1. Lowering the head of the bed to a flat position
2. Applying manual pressure over the site
3. Monitoring the client s airway
4. Calling the physician immediately
Answer:
1.
Rationale:
If the client begins to hemorrhage from the surgical site following radical neck
dissection, the nurse elevates the head of the bed to maintain airway patency and
prevent aspiration. The nurse applies pressure over the bleeding site, and calls the
physician immediately.
Strategy:
Use the process of elimination, noting the strategic word contraindicated . Options 2
and 3 are indicated if the client is hemorrhaging. Calling the physician is also
indicated immediately, but lowering the head of bed does not help with airway
maintenance. Review nursing actions if a client begins to hemorrhage if you had
Reference:
Mosby.
Inc.
Question:
The client with tuberculosis (TB) asks the nurse about precautions to take after
discharge to prevent infection of others. The nurse develops a response to the client
s question based on the understanding that:
Options:
1. The client should maintain enteric precautions only.
2. The disease is transmitted by droplet nuclei.
3. Clothing and sheets should be bleached after each use.
4. Deep pile carpet should be removed from the home.
Answer:
2.
Rationale:
Tuberculosis (TB) is spread by droplet nuclei or 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.
Strategy:
Knowing that TB is not carried on inanimate objects helps you eliminate options 3
and 4 first. To select between options 1 and 2, recall that the disease is transmitted
by the airborne route. If you had difficulty with this question, review the
transmission mode of TB.
Reference:
Inc.
Question:
The nurse is caring for the client after pulmonary angiography with catheter
insertion via the left groin. The nurse assesses for allergic reaction to the contrast
medium by noting the presence of: Options:
1. Hematoma in the left groin.
2. Discomfort in the left groin.
3. Stridor.
4. Hypothermia.
Answer:
3.
Rationale:
Signs of allergic reaction to the contrast dye include early signs such as localized
itching and edema, which are then followed by more severe symptoms such as
respiratory distress, stridor, and decreased blood pressure.
Strategy:
Focus on the subject, an allergic reaction. Hypothermia is an unrelated event and is
eliminated first. Discomfort is expected, and is eliminated next. Hematoma
formation is a complication of the procedure, but does not indicate allergic reaction,
and is therefore eliminated. The remaining option is stridor, which is a sign of a
severe allergic reaction and possible anaphylaxis. Review the signs of an allergic
reaction to the contrast medium if you had difficulty with this question.
Reference:
Pagana, K., & Pagana, T. (2005). Mosby s diagnostic and laboratory test reference
(7th ed., pp. 772- 773). St. Louis: Mosby.
Inc.
Question:
The nurse is preparing to care for a client who will be weaned from a tracheostomy
tube. The nurse is planning to use a tracheostomy plug and plans to insert it into
the opening in the outer cannula. Which of the following nursing interventions are
required prior to plugging the tube?
Options:
1. Place the inner cannula into the tube.
2. Deflate the cuff on the tube.
3. Ensure that the client is able to swallow.
4. Ensure that the client is able to speak.
Answer:
2.
Rationale:
Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug
(decannulation stopper) into the opening of the outer cannula. This closes off the
tracheostomy, and airflow and respiration occur normally through the nose and
mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it
remains inflated, ventilation cannot occur and respiratory arrest could result. The
ability to swallow or speak is unrelated to weaning and plugging the tube.
Strategy:
Note the strategic word required in the question. This should assist in directing you
to the option that addresses a priority physiological need. Use the process of
elimination to direct you to option 2, because an inflated cuff would cause airway
obstruction. Review this procedure if you had difficulty with this question.
Reference:
Mosby.
Elsevier Inc.
Question:
The nurse is caring for a client who is on strict bed rest. The nurse develops a plan
of care and develops goals related to the prevention of deep vein thrombosis (DVT)
and pulmonary emboli. Which of the following nursing actions would be most helpful
to prevent these disorders from developing? Options:
1. Applying a heating pad to the lower extremities
2. Encouraging active range-of-motion (ROM) exercises
3. Placing a pillow under the knees
4. Restricting fluids
Answer:
2.
Rationale:
Persons at greatest risk for pulmonary emboli are immobilized clients. Basic
preventive measures include early ambulation, leg elevation, active leg exercises,
elastic stockings, and intermittent pneumatic calf compression. Keeping the client
well hydrated is essential because dehydration predisposes to clotting. A pillow
under the knees may cause venous stasis. Heat should not be applied without a
physician s prescription.
Integrated Process - Nursing ProcessPlanning

Strategy:
Use the process of elimination and basic principles related to the care of the
immobile client to answer this question. If you are unfamiliar with these basic
measures, review this content.
Reference:
Elsevier Inc.
Question:
The client with tuberculosis (TB), whose status is being monitored in an ambulatory
care clinic, asks the nurse when it is permissible to return to work. The nurse replies
that the client may resume employment when:
Options:
1. Three sputum cultures are negative.
2. Five sputum cultures are negative.
3. A sputum culture and a chest x-ray are negative.
4. A sputum culture and a Mantoux test are negative.
Answer:
1.
Rationale:
The client must have sputum cultures performed every 2 to 4 weeks after initiation
of antituberculosis drug therapy. The client may return to work when the results of
three sputum cultures are negative, because the client is considered noninfectious
at that point.
Strategy:
Use the process of elimination. Knowing that a positive Mantoux test never reverts
to negative helps you eliminate option 4. From the remaining options, it is
necessary to know that three negative sputum cultures are required. If this question
was difficult, review these concepts related to TB.
Reference:
Inc.
Question:
The nurse is admitting a client to the nursing unit who is suspected of having
tuberculosis (TB). The nurse plans to admit the client to a room that has:
Options:
1. Ultraviolet light and three air exchanges per hour.
2. Ten air exchanges per hour and venting to the outside.
3. Venting to the outside and ultraviolet light.
4. Venting to the outside, six air exchanges per hour, and ultraviolet light.
Answer:
4.
Rationale:
The client is admitted to a private room that has at least six air exchanges per hour,
and that has negative pressure in relation to surrounding areas. The room should be
vented to the outside, and should have ultraviolet lights installed.
Strategy:
Use the process of elimination. Knowing that the air must vent to the outside helps
eliminate option 1. Knowing that ultraviolet light is useful in killing these organisms
helps you eliminate option 2. From the remaining options, recall that there must be
an airflow system that allows for at least six air exchanges per hour. If you had
difficulty with this question, review care of the hospitalized client with TB.
Reference:
Inc.
Question:
The nurse is monitoring the chest tube drainage system in a client with a chest
tube. The nurse notes intermittent bubbling in the water seal compartment. Which
of the following is the appropriate action? Options:
1. Change the chest tube drainage system.
2. Document the findings.
3. Check for an air leak.
4. Notify the physician.
Answer:
2.
Rationale:
Bubbling in the water seal compartment is caused by air passing out of the pleural
space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that
the system is accomplishing one of its purposes, removing air from the pleural
space. Continuous bubbling during inspiration and expiration indicates that an air
leak exists. If this occurs, it must be corrected.
Strategy:
Focus on the strategic words intermittent bubbling and water seal compartment .
Recalling that intermittent bubbling is normal will direct you to option 2. If you are
unfamiliar with chest tube drainage systems, review this content.
Reference:
Mosby.
Inc.
Question:
The client who has just suffered a large flail chest is experiencing severe pain and
dyspnea. The client s central venous pressure (CVP) is rising, and the arterial blood
pressure is falling. The nurse interprets that the client is experiencing:
Options:
1. Mediastinal flutter.
2. Mediastinal shift.
3. Hypovolemic shock.
4. Fat embolism.
Answer:
1.
Rationale:
The client with severe flail chest will have significant paradoxical chest movement.
This causes the mediastinal structures to swing back and forth with respiration. This
movement can affect hemodynamics. Specifically, the client s central venous
pressure (CVP) rises, the filling of the right side of the heart is impaired, and the
arterial blood pressure falls. This is referred to as mediastinal flutter. Level of

Strategy:
Use the process of elimination. Because the question makes no mention of
hemorrhage or bleeding, hypovolemic shock is eliminated first. Knowing that these
signs and symptoms are not compatible with fat embolism helps you eliminate that
option next. From the remaining options, knowing that mediastinal shift is a result of
tension pneumothorax helps you choose mediastinal flutter as the correct option.
Review the complications of a flail chest if you had difficulty with this question.
Reference:
Inc.
Question:
The nurse is caring for the client who is suspected of having lung cancer. The nurse
assesses the client for which most frequent early symptom of lung cancer?
Options:
1. Hemoptysis
2. Cough
3. Hoarseness
4. Pleuritic pain
Answer:
2.
Rationale:
Cough is the most frequent symptom of lung cancer, which begins as nonproductive
and hacking, and progresses to productive. In the smoker who already has a cough,
a change in the character and frequency of cough usually occurs. Wheezing and
blood-streaked sputum (hemoptysis) are later signs. Pain is a very late sign, and is
usually pleuritic in nature. Hoarseness indicates that the affected tissue is in the
upper airway.
Strategy:
Use the process of elimination. Begin to answer this question by eliminating pain
and hemoptysis, because it is reasonable that these would be later signs. To
discriminate between cough and hoarseness, think about location. Hoarseness
would indicate that the affected tissue is in the upper airway, whereas cough would
indicate lower airway. Because the question is asking about lung cancer, which is
lower airway, the answer must be cough. Review the frequent early symptoms of
lung cancer if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse has assisted the physician and the anesthesiologist with placement of an
endotracheal (ET) tube in a client in respiratory distress. Which of the following is
the initial nursing action to evaluate proper ET tube placement?
Options:
1. Ask the radiology department to obtain a stat portable radiograph at the client s
bedside. 2. Use an Ambu (resuscitation) bag to ventilate the client and assess for
bilateral breath sounds. 3. Tape the ET tube in place and note the centimeter
marking at the lip line.
4. Attach the ET tube to the ventilator and determine if the client is able to tolerate
the tidal volume prescribed.
Answer:
2.
Rationale:
The nurse verifies the placement of an ET tube immediately by ventilating the client
using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures
ventilation of both lungs. After this initial assessment, placement is then checked
radiographically. The nurse marks the ET tube at the point where it enters the nose
or mouth for ongoing monitoring of correct placement, but this will not determine
initial adequate placement of the ET tube. Noting the tidal volume and the client s
toleration of the tidal volume prescribed is not a measure of appropriate ET tube
placement.
Strategy:
Note the strategic word initial in the question. Use the process of elimination,
visualizing each of the options to assist in determining the correct option. Also, use
the ABCsairway, breathing, and circulationto assist in directing you to option 2.
If you had difficulty with this question, review care of the client after ET tube
placement.
Reference:
Inc.
Question:
A nurse is preparing to suction a client with a tracheostomy tube and gathers the
supplies needed for the procedure. Which of the following is the initial nursing
action?
Options:
1. Set the suction pressure range at 150 mm Hg.
2. Hyperoxygenate the client.
3. Place the catheter into the tracheostomy tube.
4. Apply suction on the catheter and insert it into the tracheostomy tube.
Answer:
2.
Rationale:
The nurse should hyperoxygenate the client both before and after suctioning. This
would be the initial nursing action. The safe suction range for an adult client is 100
to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube,
suction is not applied because applying suction at that time will cause mucosal
trauma and aspiration of the client s oxygen.
Strategy:
Note the strategic word initial in the question. Attempt to visualize the suctioning
procedure to assist in directing you to the correct option. Recalling that suctioning
will remove oxygen from the client will assist in directing you to option 2. Also use
the ABCsairway, breathing, and circulationto direct you to option 2. Review
suctioning procedures if you had difficulty with this question.
Reference:
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1098, 11011108). St. Louis: Mosby. page 1 Elsevier items and derived items 2008 by
Question:
A home care nurse visits a client who is started on oxygen therapy. The nurse
provides instructions to the client regarding safety measures for the use of oxygen
in the home. Which statement if made by the client indicates a need for further
instruction?
Options:
1. I need to be sure that no one smokes in my home.

2. I need to be sure that I stay at least 10 feet away from any burning candles.
3. It is all right to use an electric razor for shaving only if I leave it plugged in for a
short period of time. 4. I need to be sure that there is space between the oxygen
concentrator and the wall in the room. Answer:
3.
Rationale:
The use of small electric items, tools, or other equipment could emit sparks and
should be avoided while oxygen is in use. The use of this equipment could result in
fire and injury to the client. The oxygen concentrator is kept away from walls and
corners to permit adequate airflow. The client also should be instructed not to allow
smoking in the home and to stay at least 10 feet away from any type of flame.
Strategy:
Use the process of elimination. Note the strategic words need for further instruction
. This phrasing indicates a negative event query and directs you to select an
incorrect statement. Focusing on the subject, oxygen safety, will direct you to option
3. If you had difficulty with this question, review the highlights of home oxygen
safety.
Reference:
Elsevier Inc.
Question:
A clinic nurse is performing an assessment on a client who is complaining of
shortness of breath. The client tells the nurse that he is a cigarette smoker and
admits to smoking one pack of cigarettes per day for the past 10 years. The nurse
determines that the client has a smoking history of how many pack- years?
Options:
1. 7.5
2. 10
3. 15
4. 20
Answer:
2.
Rationale:
The standard method for quantifying the smoking history is to multiply the number
of packs smoked per day by the number of years of smoking. The number is then
recorded as the number of pack-years. The calculation for the number of pack-years
for the client in this question who smokes 1 pack per day for 10 years is 1 pack
10 years = 10 pack-years.
Strategy:
Knowledge regarding history taking related to smoking and knowledge of the
formula for determining the pack-years is required to answer this question.
Remember to multiply the number of packs smoked per day by the number of years
of smoking. Review this formula if you are unfamiliar with it.
Reference:
Inc.
Question:
A nurse is performing a respiratory assessment and is auscultating the client s
breath sounds. On auscultation, the nurse hears a grating and creaking type of
sound. The nurse interprets that this client has:
Options:
1. Rhonchi
2. Crackles
3. Pleural friction rub
4. Wheezes
Answer:
3.
Rationale:
A pleural friction rub is characterized by sounds that are described as creaking,
groaning, or grating in quality. The sounds are localized over an area of
inflammation on the pleura and may be heard in both the inspiratory and expiratory
phases of the respiratory cycle. Crackles have the sound that is heard when a few
strands of hair are rubbed together and indicate fluid in the alveoli. Rhonchi are
usually heard on expiration when there is an excessive production of mucus that
accumulates in the air passages. Wheezes are musical noises heard on inspiration,
expiration, or both and are the result of narrowed airway passages.
Strategy:
Use knowledge of respiratory assessment data and breath sounds to answer this
question. Focusing on the strategic words grating and creaking will direct you to
option 3. If you are unfamiliar with the characteristics of the various breath sounds,
review this content.
Reference:
Inc.
Question:
A nurse is preparing to assist a physician with the removal of a client s chest tube.
The nurse gathers items that will be needed for this procedure. Which of the
following items are unnecessary for removal of the chest tube?
Options:
1. Petrolatum gauze dressing
2. Telfa dressing
3. A sterile 4 4 gauze
4. Adhesive tape
Answer:
2.
Rationale:
On removal of a chest tube, a sterile petrolatum gauze dressing is applied to the
chest tube insertion site, followed by a sterile gauze pad and adhesive tape. The
entire dressing is securely taped to ensure that it remains occlusive. The petrolatum
dressing is the key element for an airtight seal at the chest tube insertion site. A
Telfa dressing is not used and is not indicated for this procedure. Although this is the
usual procedure, somewhat different procedures may be used in accordance with
physician preferences and agency protocols.
Strategy:
Use the process of elimination. Recalling that an occlusive seal is needed after the
removal of a chest tube will direct you to option 2. If you had difficulty with this
question, review the procedure for chest tube removal.
Reference:
Inc.
Question:
A nurse is providing instructions to a client being discharged from the hospital
following removal of a chest tube that was inserted following thoracic surgery.
Which of the following statements if made by the client indicates a need for further
instruction?
Options:
1. If I note any signs of infection, I should contact the physician.
2. If I have any difficulty in breathing, I should call the physician.
3. I should remove the chest tube site dressing when I get home.
4. I should avoid heavy lifting for at least 4 to 6 weeks.
Answer:
3.
Rationale:
When a chest tube is removed, an occlusive dressing consisting of petrolatum gauze
covered by a dry sterile dressing usually is placed over the chest tube site. This
dressing is maintained in place until the physician says that it may be removed. The
client is taught to monitor and report any signs of respiratory difficulty or any signs
of infection or increased temperature. The client should avoid heavy lifting for 4 to 6
weeks after discharge to facilitate continued wound healing.
Strategy:
Note the strategic words need for further instruction . This phrasing indicates a
negative event query and directs you to select an incorrect statement. Reading
each option carefully and use of the process of elimination will assist in directing
you to option 3. Review client teaching points after removal of a chest tube if you
Reference:
Inc.
Question:
A nursing student is performing a respiratory assessment on a female adult client
and is assessing for tactile fremitus. The nurse observing the student intervenes if
the student performs which incorrect technique?
Options:
1. Palpating over the lung apices in the supraclavicular area
2. Asking the client to repeat the word ninety-nine during palpation
3. Palpating over the breast tissue to assess and compare vibrations from one side
to the other 4. Comparing vibrations from one side to the other as the client repeats
the word ninety-nine Answer:
3.
Rationale:
When assessing for tactile fremitus, the nurse should begin palpating over the lung
apices in the supraclavicular area. The nurse should compare vibrations from one
side to the other as the client repeats the word ninety-nine. The nurse should
avoid palpating over female breast tissue because breast tissue usually blocks the
sound.
Strategy:
Note the strategic word incorrect in the question. This indicates a negative event
query and directs you to select an incorrect technique. Eliminate options 2 and 4
first, because they are comparative or alike. Regarding the remaining options,
recalling that breast tissue blocks sound will direct you to this option. Review the
technique of performing assessment for tactile fremitus if you had difficulty with this
question.
Reference:
Inc.
Question:
A nursing instructor is observing a nursing student suctioning a client through a
tracheostomy tube. Which observation by the nursing instructor would indicate an
inappropriate action?
Options:
1. Hyperventilating the client with 100% oxygen before suctioning
2. Applying suction intermittently during withdrawal of the catheter
3. Suctioning the client every hour
4. Applying suction only during withdrawal of the catheter
Answer:
3.
Rationale:
The client should be suctioned as needed. Unnecessary suctioning needs to be
avoided because it can increase secretions and cause mechanical trauma to the
tissues. The client should be hyperoxygenated with 100% oxygen before suctioning.
Suction is not applied during insertion of the catheter, and intermittent suction and
a twirling motion of the catheter are used during withdrawal.
Strategy:
Note the strategic word inappropriate and visualize the procedure. Noting the words
every hour in option 3 and thinking about the effects of suctioning will direct you to
this option. The client should be suctioned as needed, not on a preset scheduled
time unless specifically required and indicated by the physician. Review the
procedure for suctioning if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is changing the tracheotomy ties on a client with a tracheotomy and is
assessing the security of the ties. What method is used to ensure that the ties are
not too tightly placed?
Options:
1. The nurse places two fingers between the tie and the neck.
2. The tracheotomy can be pulled slightly away from the neck.
3. The ties leave no marks on the neck.
4. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.
Answer:
1.
Rationale:
The nurse should assess the tracheostomy ties to ensure that they are not too tight.
The nurse ensures that there is room for two fingers to slide comfortably under the
ties. Options 2, 3, and 4 are incorrect. Level of Cognitive Ability - Application
Strategy:
Use the process of elimination, noting the subject of the question. Option 4 can be
eliminated because of the word tightly . Next, eliminate options 2 and 3 because
these are not appropriate methods for assessing tightness of the ties. If you had
difficulty with this question, review care for a tracheostomy. Reference:
Inc.
Question:
A nurse is preparing for removal of an endotracheal (ET) tube from a client. In
assisting the physician in this procedure, which initial nursing action is appropriate?
Options:
1. Suction the ET tube.
2. Deflate the cuff.
3. Turn off the ventilator.
4. Obtain a code cart and place it at the bedside.
Answer:
1.
Rationale:
Once the client has been weaned successfully and has achieved an acceptable level
of consciousness to sustain spontaneous respiration, an ET tube may be removed.
The ET tube is suctioned first, and then the cuff is deflated and the tube is removed.
Placing a code cart at the bedside is unnecessary and may cause alarm and concern
in the client. Additionally, resuscitative equipment should already be available at
the client s bedside. Option 3 is not the initial action.
Strategy:
Note the strategic word initial . Use the ABCsairway, breathing, and circulation.
Option 1 addresses airway. Remember that airway is the first priority. Review this
procedure if you had difficulty with this question.
Reference:
positive outcomes (7th ed., pp. 1888, 1893-1894). Philadelphia: W.B. Saunders.
Inc.
Question:
A client is intubated with an endotracheal (ET) tube by the anesthesiologist. What is
the responsibility of the nurse with regard to checking for tube placement
immediately after tube insertion?
Options:
1. It is not the responsibility of the nurse to check for tube placement.
2. Arrange for a chest radiograph.
3. Auscultate the lungs for the presence of bilateral breath sounds.
4. Instill air into the ET tube and listen for its being forced into the lungs.
Answer:
3.
Rationale:
Immediately after an ET tube is inserted, tube placement is verified by both
auscultation and chest radiography. Auscultating the lungs would be the immediate
action, and the nurse would auscultate for bilateral breath sounds. Option 4 is an
inappropriate action.
Strategy:
Use the process of elimination. Noting the strategic word immediately in the
question will direct you to option 3. Although a nurse will prepare the client for a
chest radiograph, the immediate action is to auscultate for bilateral breath sounds.
Review the procedure for checking ET tube placement after insertion if you had
Reference:
Inc.
Question:
A nurse is performing nasotracheal suctioning of a client. The nurse interprets that
the client is adequately tolerating the procedure if which of the following
observations is made?
Options:
1. Secretions are becoming bloody.
2. Heart rate decreases from 78 to 54 beats/min.
3. Coughing occurs with suctioning.
4. Skin color becomes cyanotic.
Answer:
3.
Rationale:
The nurse monitors for adverse effects of suctioning, which include cyanosis,
excessively rapid or slow heart rate, and sudden development of bloody secretions.
If any of these signs is observed, the nurse immediately stops suctioning and
reports the adverse effect to the physician. Coughing is a normal response to
suctioning for the client with an intact cough reflex and does not indicate that the
client cannot tolerate the procedure.

Strategy:
Use the process of elimination, noting the strategic words tolerating the procedure .
Cyanosis and bradycardia are abnormal findings and are eliminated first. Because
the cough reflex normally is present and suctioning triggers coughing, this is the
preferable option from the two remaining. Review the complications associated with
suctioning if you had difficulty with this question.
Reference:
Elsevier Inc.
Some material was previouQuestion:
A nurse is performing nasotracheal suctioning of a client. The nurse interprets that
the client is adequately tolerating the procedure if which of the following
observations is made?
Options:
1. Secretions are becoming bloody.
2. Heart rate decreases from 78 to 54 beats/min.
3. Coughing occurs with suctioning.
4. Skin color becomes cyanotic.
Answer:
3.
Rationale:
The nurse monitors for adverse effects of suctioning, which include cyanosis,
excessively rapid or slow heart rate, and sudden development of bloody secretions.
If any of these signs is observed, the nurse immediately stops suctioning and
reports the adverse effect to the physician. Coughing is a normal response to
suctioning for the client with an intact cough reflex and does not indicate that the
client cannot tolerate the procedure.
Strategy:
Use the process of elimination, noting the strategic words tolerating the procedure .
Cyanosis and bradycardia are abnormal findings and are eliminated first. Because
the cough reflex normally is present and suctioning triggers coughing, this is the
preferable option from the two remaining. Review the complications associated with
suctioning if you had difficulty with this question.
Reference:
Elsevier Inc.
Question:
A client with a tracheostomy tube on a ventilator is at risk for impaired gas
exchange. The nurse should assess for which of the following items as the best
indicator of adequate ongoing respiratory status? Options:
1. Moderate amounts of tracheobronchial secretions
2. Small to moderate amounts of frank blood suctioned from the tube
4. Oxygen saturation of 91%
Answer:
3.
Rationale:
Impaired gas exchange could occur after tracheostomy from excessive secretions,
bleeding into the trachea, restricted lung expansion due to immobility, or
concurrent respiratory conditions. An oxygen saturation of 91% is less than optimal.
A respiratory rate of 16 breaths/min is in the normal range. Level of Cognitive
Ability - Analysis
Strategy:
Focus on the subject, the best indication of normal respiratory status. An oxygen
saturation of 91% is suboptimal and is eliminated first. Bloody secretions (option 2)
also are abnormal, although secretions may be blood tinged for a few days after
tracheostomy insertion. Although tracheobronchial secretions may be expected,
they are not the best indication of respiratory adequacy, making option 3 correct.
Review care of the client after creation of a tracheostomy if you had difficulty with
this question. Reference:
Inc.
Question:
A nurse is monitoring the respiratory status of a client after creation of a
tracheostomy. The nurse understands that oxygen saturation measurements
obtained by pulse oximetry may be inaccurate if the client has which of the
following coexisting problems?

Options:
1. Hypotension
2. Fever
3. Respiratory failure
4. Epilepsy
Answer:
1.
Rationale:
Hypotension, shock, or the use of peripheral vasoconstricting medications may
result in inaccurate pulse oximetry readings from impaired peripheral perfusion.
Fever and epilepsy would not affect the accuracy of measurement. Respiratory
failure also would not affect the accuracy of measurement, although the readings
may be abnormally low.
Strategy:
Recall that pulse oximetry measures oxygen saturation in blood flowing through the
blood vessels in the periphery of the body and that inaccurate measurement may
result from any factor that impairs blood flow through the periphery. Evaluating
each of the options from this standpoint will help you to select hypotension as the
answer. Review the concepts related to pulse oximetry if you had difficulty with this
question.
Reference:
Inc.
Question:
A nurse is monitoring the function of a client s chest tube that is attached to a
Pleur-Evac drainage system. The nurse notes that the fluid in the water seal
chamber rises with inspiration and falls with expiration. The nurse interprets that:
Options:
1. The client has residual pneumothorax.
2. The system is patent.
3. Suction should be added to the system.
4. There is a leak in the system.
Answer:
2.
Rationale:
When the chest tube is patent, the fluid in the water seal chamber rises with
inspiration and falls with expiration. This is referred to as tidaling and indicates
proper function of the system. Options 1, 3, and 4 are inaccurate interpretations.
Strategy:
Use the process of elimination. Recalling that negative pressure (pulling pressure)
develops with inspiration, it is natural that the fluid level in the water seal chamber
would rise on inspiration. Consequently, with expiration, the opposite naturally
would be true. This makes options 3 and 4 incorrect. Select option 2 over option 1
because the question makes no mention of bubbling in the water seal chamber,
which would occur if the client had pneumothorax. Review care of a client with a
chest tube if you had difficulty with this question.
Reference:
Inc.
Question:
An older client is diagnosed with a rib fracture and asks the nurse why strapping the
ribs is not being done. Which response by the nurse is appropriate?
Options:
1. That isn t done anymore because people often would develop pneumonia from
the constricting effect on the lungs.
2. That might help you to breathe better, but this facility does not carry the
necessary supplies in the stockroom. When you get home, you can purchase them
at the medical supply store.
3. Strapping is useful only if the ribs are fractured in several places at once.
4. That s a good idea. I ll ask the physician for an order for the needed supplies.
Answer:
1.
Rationale:
Strapping the ribs has a constricting effect on the ribs and deep breathing and can
actually increase the risk of atelectasis and pneumonia. Therefore, options 2, 3, and
4 are incorrect.
Strategy:
Use the process of elimination and answer the question by logically thinking through
the physiological effects of restricting lung mobility. This will direct you to option 1.
Review interventions for rib fractures if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is caring for a postoperative pneumonectomy client. Which of the following
findings on nursing assessment of the client would be an adverse sign/symptom
indicating pulmonary edema? Options:
2. Pain with deep breathing
3. Lung crackles
4. Increased chest tube drainage
Answer:
3.
Rationale:
The client with pulmonary edema that developed after pneumonectomy
demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A
respiratory rate of 20 breaths/min is within normal limits. Pain with deep breathing
is expected and is managed with analgesics. The client with pneumonectomy most
likely will not have a chest tube.
Strategy:
Use the process of elimination. Increased chest drainage indicates hemorrhage, not
pulmonary edema, and is eliminated first. Additionally, the client with
pneumonectomy most likely will not have a chest tube. A respiratory rate of 20
breaths/min is normal, and pain with deep breathing is expected in the immediate
postoperative period, so these may be eliminated next. Crackles in lung fields
indicate pulmonary edema and is the correct option. Review the signs of pulmonary
edema if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A nurse reads a client s Mantoux skin test as positive and notes that previous tests
were negative. The client becomes upset and asks the nurse what this means. The
nurse s response is based on the understanding that the client has:
Options:
1. No evidence of tuberculosis
2. Systemic tuberculosis
3. Pulmonary tuberculosis
4. Exposure to tuberculosis
Answer:
4.
Rationale:
A client who tests positive on a Mantoux skin test either has been exposed to
tuberculosis or has inactive (dormant) tuberculosis. The client must then undergo
chest radiography and sputum culture to confirm the diagnosis.
Client Needs - Psychosocial Integrity
Strategy:
Use the process of elimination, eliminating options 2 and 3 first because they are
comparative or alike in that both indicate the presence of tuberculosis. Regarding
the remaining options, note that the result on Mantoux skin testing is positive.
Therefore, eliminate option 1. Because of the importance of this test, review this
content if the question was difficult for you.
Reference:
Inc.
Question:
A nurse is caring for a client with tuberculosis who is fearful of the disease and
anxious about prognosis. In planning nursing care, the nurse should incorporate
which of the following as the best strategy to assist the client in coping with the
illness?
Options:
1. Encourage the client to visit with the pastoral care department chaplain.
2. Ask family members if they wish a psychiatric consult.
3. Provide reassurance that continued compliance with medication therapy is the
most proactive way to cope with the disease.
4. Allow the client to deal with the disease in an individual fashion.
Answer:
3.
Rationale:
A primary role of the nurse in working with the client with tuberculosis is to teach
the client about medication therapy. The anxious client may not absorb information
optimally. The nurse continues to reinforce teaching using a variety of methods
(repetition, teaching aids) and teaches the family about the medications as well.
The most effective way of coping with the disease is to learn about the therapy,
which will eradicate it. This gives the client a measure of power over the situation
and outcome. Level of Cognitive Ability - Application
Integrated Process - Caring
Strategy:
Note the subject, the best strategy for coping with anxiety about the disease and its
prognosis. Options 2 and 4 are the least useful and may be eliminated first. Option 2
does not involve the client, and option 4 gives no active assistance to the client.
Regarding the remaining options, recalling the importance of medication therapy
will direct you to option 3. Review the psychosocial concerns related to tuberculosis
if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse has instructed a client diagnosed with tuberculosis about how to prevent
the spread of infection after discharge from the hospital. The nurse evaluates that
the client needs further reinforcement of information if the client makes which of
the following statements?
Options:
1. It s very important to wash my hands after I touch my mask, tissues, or body
fluids.
2. I should cough into tissues and throw them away carefully.
3. It s important to cover my mouth if I laugh, sneeze, or cough.
4. I should use disposable plates, forks, and knives.
Answer:
4.
Rationale:
Because tuberculosis is transmitted by droplet, it cannot be carried on clothing,
eating utensils, or other possessions. It is not necessary to discard any of these. It is
important to perform proper hand washing after contact with body substances,
tissues, or face masks. The client should cover the mouth with a tissue when
laughing, coughing, or sneezing and dispose of tissues carefully. The client also may
need to wear a mask as advised by the physician.
Strategy:
Note the strategic words needs further reinforcement . This phrasing indicates a
negative event query and asks you to select an incorrect statement. Recall that
tuberculosis is an airborne disease, so the organisms cannot be carried on
inanimate objects. Review client teaching points related to the prevention of the
spread of tuberculosis if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis
and is worried about the possibility of infecting family and others. The nurse
provides the reassurance by telling the client that:
Options:
1. The family does not need therapy, and the client will not be contagious after 1
month of drug therapy. 2. The family does not need therapy, and the client will not
be contagious after 6 consecutive weeks of drug therapy.
3. The family will receive prophylactic therapy, and the client will not be contagious
after 1 continuous week of drug therapy.
4. The family will be treated prophylactically, and the client will not be contagious
after 2 to 3 consecutive weeks of drug therapy.
Answer:
4.
Rationale:
Family members or others who have been in close contact with a client diagnosed
with tuberculosis are placed on prophylactic therapy with isoniazid (INH) for 6 to 12
months. The client usually is 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 tuberculosis. Level of
Integrated Process - Caring
Strategy:
Use the process of elimination. Recalling that the family requires prophylactic
therapy helps you to eliminate options 1 and 2. Regarding the remaining options,
recall that the client is not contagious after 2 to 3 weeks of therapy. Review the
concepts related to the prevention of the spread of tuberculosis if you had difficulty
with this question.
Reference:
Mosby.
Inc.
Question:
A client diagnosed with tuberculosis is distressed over the loss of physical stamina
and fatigue. The nurse plans to teach the client that:
Options:
1. This is a short-lived problem, which should be gone within 1 week of drug
therapy.
2. This is an unexpected finding with tuberculosis, but it should resolve within 1
month or so. 3. This is expected, and the client should gradually increase activity as
tolerated.
4. This is expected and will last for at least 1 year.
Answer:
3.
Rationale:
The client with tuberculosis has significant fatigue and loss of physical stamina. This
can be very frightening for the client. The nurse teaches the client that this will
resolve as the therapy progresses and that the client should gradually increase
activity as energy levels permit. Options 1, 2, and 4 are incorrect.
Strategy:
A helpful concept to remember in answering this question is that fatigue due to

respiratory problems may not resolve easily and is an expected occurrence, due to
tissue hypoxia. Knowing this, you can eliminate options 1 and 2 first. From the
remaining options, select option 3 because it provides accurate information and is
reassuring. Review client education points related to tuberculosis if you had
Reference:
Mosby.
Inc.
Question:
A nurse is assessing a client with the typical clinical manifestations of tuberculosis.
The nurse would expect the client to report having fatigue and cough that have
been present for:
Options:
1. 1 or 2 days
2. Almost 1 week
3. 1 to 2 weeks
4. Several weeks to months
Answer:
4.
Rationale:
The client with tuberculosis may report signs and symptoms that have been present
for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia
and weight loss, night sweats, low- grade fever, and cough with mucoid or bloodstreaked sputum. It may be the production of blood-tinged sputum that finally
forces some clients to seek care.
Strategy:
Use the process of elimination. Eliminate options 2 and 3 because they are
comparative or alike. From the remaining options, eliminate option 1 because of the
short time period. Review the clinical manifestations of tuberculosis if you had
Reference:

Inc.
Question:
A client with active tuberculosis demonstrates less-than-expected interest in
learning about the prescribed medication therapy. The nurse assesses that this
client may ultimately need:
Options:
1. More medication instructions
2. Involvement of the family in teaching
3. Reinforcement by the physician
4. Directly observed therapy
Answer:
4.
Rationale:
Tuberculosis is a highly communicable disease that is reportable to the local public
health department. This agency has regulations that may be enforced to ensure
compliance with tuberculosis therapy. The client may be required to have directly
observed therapy to reduce the risk to the general public. This involves having a
responsible person actually observe the client taking the medication each day.
Strategy:
Note the word ultimately . This implies an action that would be taken as a last
resort. Knowing that tuberculosis is a highly communicable, reportable disease, you
would eliminate options 1, 2, and 3. This leaves directly observed therapy, which is
closely overseen and enforced through the public health department. Review the
interventions that will ensure medication compliance if you had difficulty with this
question.
Reference:
Inc.
Question:
A client experienced an open pneumothorax and a chest wound, which has been
covered with an occlusive dressing. The client begins to experience severe dyspnea,
and the blood pressure begins to fall. The nurse should first:
Options:
1. Remove the dressing.
2. Reinforce the dressing.
4. Measure oxygen saturation by oximetry.
Answer:
1.
Rationale:
Placement of a dressing over a chest wound could convert an open pneumothorax
to a closed (tension) pneumothorax. This may result in a sudden decline in
respiratory status, mediastinal shift with twisting of the great vessels, and
circulatory compromise. If clinical changes occurs, the nurse removes the dressing
immediately, allowing air to escape.
Strategy:
Use the process of elimination and note the strategic word first . Remembering that
an open pneumothorax can be transformed into a tension pneumothorax with
closure will direct you to option 1. Review the nursing actions for a client with an
open pneumothorax if you had difficulty with this question.
Reference:
Inc.
Question:
A clinic nurse administers a Mantoux skin test to a client. The nurse tells the client
to return to the clinic for reading the results in:
Options:
1. 24 to 36 hours
2. 24 to 48 hours
3. 36 to 48 hours
4. 48 to 72 hours
Answer:
4.
Rationale:
The Mantoux skin test is the most accurate and reliable tuberculin skin test
currently available. Interpretation of the Mantoux test result should be done 48 to
72 hours after the injection.

Strategy:
Knowledge of the correct reading times after a Mantoux skin test is required to
answer this question. Remember that the reading time is 48 to 72 hours after
injection. Review this content if you had difficulty with this question.
Reference:
Inc.
Question:
A client who has undergone radical neck dissection for a tumor has a nursing
diagnosis of ineffective airway clearance related to obstruction secondary to
postoperative edema, drainage, and secretions. To promote adequate respiratory
function in this client, the nurse needs to avoid which of the following activities?
Options:
1. Placing the bed in low Fowler s position
2. Supporting the neck incision when the client coughs
3. Suctioning the client as needed
4. Encouraging coughing every 2 hours
Answer:
1.
Rationale:
The client s respiratory status is promoted by the use of high Fowler s position
after this surgery. Low Fowler s position is avoided because it could result in
increased venous pressure on the graft and increased risk of regurgitation and
aspiration. It also is helpful to encourage the client to cough and deep breathe
every 2 hours, to support the neck incision when the client coughs, and to suction
periodically as needed by the client.
Strategy:
Note the strategic word avoid in the question. Noting the anatomical location of the
surgical procedure and knowledge of basic principles of airway management will
direct you to option 1. Remember that the head of the bed needs to be elevated.
Review the basic principles of promoting adequate respiratory function if you had
Reference:
Inc.
Question:
A client is seen in the health care clinic and a diagnosis of acute sinusitis is made.
The nurse provides home care instructions to the client regarding measures that will
promote sinus drainage and comfort. Which statement by the client indicates a
need for further instruction?
Options:
1. I should apply heat, such as a wet pack, over the sinuses.
2. I should use a warm mist vaporizer to liquify secretions.
3. I should drink large amounts of fluids.
4. I should try to sleep with the head of the bed elevated.
Answer:
2.
Rationale:
The nurse provides instructions to the client regarding measures to promote sinus
drainage, comfort, and resolution of the infection. The nurse instructs the client to
apply heat in the form of wet packs over the affected sinuses to promote comfort
and help resolve the infection. The client should be instructed to use a cool mist
vaporizer to help liquify secretions and promote drainage. Consumption of large
amounts of fluids is important to help liquify secretions. Sleeping with the head of
the bed elevated to a 45-degree angle will assist in promoting drainage.
Strategy:
Note the strategic words indicates a need for further instruction and promote sinus
drainage and comfort . Use the process of elimination, recalling that a cool mist will
assist in liquifying secretions. If you had difficulty with this question, review client
teaching points related to acute sinusitis.
Reference:
Inc.
Question:
A clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The
nurse instructs the client to:

Options:
1. Drink warm tea throughout the day.
2. Drink warm hot chocolate in place of coffee.
3. Avoid foods that are highly seasoned.
4. Restrict fluid intake to 1000 mL daily.
Answer:
3.
Rationale:
The client with pharyngitis should be instructed to consume cool clear fluids, ice
chips, or ice pops to soothe the painful throat. Citrus products should be avoided
because they irritate the throat. Milk and milk products are avoided because they
tend to increase mucus production. Foods that are highly seasoned are irritating to
the throat and should be avoided, and the client should be instructed to eat bland
foods and drink 2000 to 3000 mL of fluid daily unless contraindicated.
Strategy:
Use the process of elimination. Recalling that pharyngitis is an inflammation of the
throat will direct you to option 3. Review teaching points for the client with
pharyngitis if you had difficult with this question. Reference:
Inc.
Question:
An ambulatory care nurse is preparing a list of instructions for the adult client who
is being discharged after tonsillectomy. The nurse avoids placing which of the
following on the list?
Options:
1. Avoid hot fluids.
2. Consume carbonated beverages and milk products.
3. Avoid raw vegetables.
4. Rest in bed or on a couch for 24 hours.
Answer:
2.
Rationale:
After tonsillectomy, the client is instructed to advance the diet from cool clear
liquids to full liquids. Hot fluids and carbonated beverages should be avoided
because they may be irritating to the throat. Milk and milk products are avoided
because they may cause the client to cough, which could cause pain at the surgical
site. Foods and snacks that are rough in texture, such as raw fruits or vegetables,
should be avoided for 10 days to protect the operative site and to prevent bleeding.
The client should be instructed to rest in bed or on a couch for 24 hours after the
surgical procedure and gradually resume full activity. Level of Cognitive Ability Application
Strategy:
Note the strategic word avoids . Use the process of elimination, focusing on the
anatomical location of the operative procedure to assist in directing you to option 2.
If you had difficulty with this question, review client teaching points after
tonsillectomy.
Reference:
Inc.
Question:
A client arrives in the hospital emergency department with a bloody nose. The initial
nursing action is to: Options:
1. Place the client in supine position.
2. Apply an ice collar around client s neck.
3. Assist the client to a sitting position with the head tilted forward.
4. Instruct the client to swallow the blood until the bleeding can be controlled.
Answer:
3.
Rationale:
The initial nursing action to treat the client with a bloody nose is to loosen clothing
around the neck to prevent pressure on the carotid artery. The client should be
assisted to a sitting position with the head tilted slightly forward, and pressure
should be applied to the nares by pitching the nose toward the septum for 10
minutes. Ice packs can be applied to the nose and forehead. If these actions are not
successful in controlling the bleeding, an ice collar may be applied, along with a
topical vasoconstrictive medication. The physician also may prescribe packing of
the nostrils. The client should be provided with an emesis basin and should be
instructed not to swallow blood, to reduce the risk of nausea and vomiting.
Strategy:
Note the strategic word initial in the question. Attempt to visualize the interventions
that would be taken in this situation. This will direct you to option 3. If you had
difficulty with this question, review initial interventions for the client experiencing
epistaxis.
Reference:
Inc.
Question:
A nurse provides instructions to a client after a total laryngectomy. Which statement
by the client indicates a need for further instruction?
Options:
1. Soaps should be avoided near the stoma.
2. I should use diluted alcohol on the stoma to clean it.
3. I should apply a thin layer of petroleum to the skin surrounding the stoma.
4. I need to protect the stoma from water.
Answer:
2.
Rationale:
The client with a stoma should be instructed to wash the stoma daily with a wash
cloth. Soaps, cotton swabs, or tissues should be avoided because their particles
may enter and obstruct the airway. The client should be instructed to avoid applying
diluted alcohol to a stoma because it is both drying and irritating. A thin layer of
petroleum applied to the skin around the stoma helps to prevent cracking. The
client is instructed to protect the stoma from water.
Strategy:
Note the strategic words need for further instruction in the question. This phrasing
indicates a negative event query and asks you to select an incorrect statement. Use
the process of elimination, thinking about the measures that will irritate the stoma.
This will direct you to option 2. If you had difficulty with this question, review these
measures.
Reference:
Inc.
Question:
A nurse is caring for a client with a tracheostomy tube who is receiving mechanical
ventilation. The nurse is monitoring for complications related to the tracheostomy
and suspects tracheoesophageal fistula when:
Options:
1. Suctioning is required frequently.
2. Excessive secretions are suctioned from the tube and stoma.
3. The client s skin and mucous membranes are light pink in color.
4. Aspiration of gastric contents occurs during suctioning.
Answer:
4.
Rationale:
Necrosis of the tracheal wall can lead to formation of an abnormal opening between
the posterior trachea and the esophagus. The opening, called a tracheoesophageal
fistula, allows air to escape into the stomach, causing abdominal distention. It also
causes aspiration of gastric contents. Options 1, 2, and 3 are not signs of this
complication.
Strategy:
Use knowledge of anatomy and medical terminology to assist you in answering this
question. A fistula is an abnormal opening, and the term tracheoesophageal means
trachea-to-esophagus. This will direct you to option 4. Review the signs of
tracheoesophageal fistula if you had difficulty with this question. Reference:
Inc.
Question:
A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm
sounds. The nurse assesses the client and attempts to determine the cause of the
alarm. Which of the following initial nursing actions would be appropriate if the
nurse is unable to determine the cause of ventilator alarm? Options:
2. Call the respiratory therapy department.
3. Shut the alarm off.
4. Manually ventilate the client with a resuscitation device.

Answer:
4.
Rationale:
If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a
mechanical ventilator, the nurse should manually ventilate the client with a
resuscitation device. The nurse should never shut off the alarms. It is not necessary
to contact the physician, although the respiratory therapist may be notified to assist
in troubleshooting the cause of the problem. However, the initial nursing action
would be to manually ventilate the client.
Strategy:
Read the information presented in the question carefully. Note the strategic word
initial in the question. Use the ABCsairway, breathing, and circulationto direct
you to option 4. If you had difficulty with this question or are unfamiliar with the
care of the client on a ventilator, review this content.
Reference:
Inc.
Question:
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an
endotracheal tube. The nurse determines that the cause for alarm activation may
be which of the following?
Options:
1. Excessive secretions
2. The presence of a mucous plug
3. Kinks in the ventilator tubing
4. Displacement of the endotracheal tube
Answer:
4.
Rationale:
The low-exhaled volume alarm will sound if the client does not receive the preset
tidal volume. Possible causes of inadequate tidal volume include disconnection of
the ventilator tubing from the artificial airway, a leak in the endotracheal or
tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube,
and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would
cause the high-pressure alarm to sound.

Strategy:
Note the strategic words low-exhaled volume alarm in the question. Use the process
of elimination, thinking about the causes of low exhaled volume to direct you to
option 4. If you are unfamiliar with the causes of ventilator alarms, review this
content.
Reference:
Inc.
Question:
A nurse is caring for a client with an endotracheal tube attached to a mechanical
ventilator. The high- pressure alarm sounds, and the nurse assesses the client. The
nurse determines that the cause of the alarm is most likely to be due to which of the
following?
Options:
1. A leak in the endotracheal tube cuff
2. Displacement of the endotracheal tube
3. A disconnection of the ventilator tubing
4. A kink in the ventilator circuit
Answer:
4.
Rationale:
A high-pressure alarm occurs if the amount of pressure needed for ventilating a
client exceeds the preset amount. Causes of high-pressure alarm activation include
excess secretions, mucous plugs, the client s biting on the endotracheal tube, kinks
in the ventilator tubing, and the client s coughing, gagging, or attempting to talk.
Strategy:
Focus on the strategic words high pressure . Thinking about this concept will direct
you to option 4. If you had difficulty with this question, review the causes of the
high-pressure alarm activation on a ventilator. Reference:
Inc.
Question:
A physician writes an order to begin to wean the client from the mechanical
ventilator by use of intermittent mandatory ventilation/synchronized intermittent
mandatory ventilation (IMV/SIMV). The nurse determines that the process of
weaning will occur by:
Options:
1. Gradually decreasing the respiratory rate until the client can assume the work of
breathing without ventilatory assistance
2. Providing pressure support to decrease the workload of breathing and increase
the client s ability to initiate spontaneous breathing efforts
3. Attaching a T-piece to the ventilator and providing supplemental oxygen at a
concentration that is 10% higher than the ventilator setting
4. Removing the ventilator from the client and closely monitoring the client s ability
to breathe spontaneously for a predetermined amount of time
Answer:
1.
Rationale:
IMV/SIMV is one of the methods used for weaning. With this method, the respiratory
rate is gradually decreased until clients assumes all of the work of breathing on
their own. This method works exceptionally well in the weaning of clients from
short-term mechanical ventilation, such as that used in clients who have undergone
surgery. The respiratory rate frequently is decreased in increments on an hourly
basis until the client is weaned and is ready for extubation.
Strategy:
Use the process of elimination. Focus on the name and description of the type of
weaning process to assist in directing you to option 1. If you had difficulty with this
question, review this method of weaning a client from a ventilator.
Reference:
Inc.
Question:
A nurse is preparing to wean a client from a ventilator by the use of a T-piece.
Which of the following would not be a component of the plan of care with this type
of weaning process?
Options:
1. The client is removed from the mechanical ventilator for a short period of time.
2. The T-piece is connected to the client s artificial airway.
3. Supplemental oxygen is provided through the T-piece at an FIO2 (fraction of
inspired oxygen) that is 10% higher than a ventilator setting.
4. The respiratory rate on the ventilator is gradually decreased until the client can
do all of the work of breathing on his or her own.
Answer:
4.
Rationale:
The T-piece (or Briggs device) requires that the client be removed from the
mechanical ventilation for short periods of time, usually beginning with a 5-minute
period. The ventilator is disconnected and the T- piece is connected to the client s
artificial airway. Supplemental oxygen is provided through the device, often at an
FIO2 that is 10% higher than the ventilator setting.
Strategy:
Use the process of elimination. Note the strategic word not in the question. Focus on
the subject, T- piece, to assist in directing you to option 4. If you had difficulty with
this question, review the process of weaning a client from a mechanical ventilator
using a T-piece.
Reference:
Inc.
Question:
A nurse is reviewing the ventilator settings on a client with an endotracheal tube
attached to mechanical ventilation. The nurse notes that the tidal volume is set at
700 mL and determines that the tidal volume indicates:
Options:
1. The number of breaths that the client will receive per minute by the ventilator
2. The amount of air delivered with each set breath
3. The fraction of inspired oxygen (FIO2) that is delivered to the client through the
ventilator 4. A breath that has a greater volume than the preset tidal volume
Answer:
2.
Rationale:
Tidal volume is the amount of air delivered with each set breath on the mechanical
ventilator. The respiratory rate is the number of breaths to be delivered by the
ventilator. The fraction of inspired oxygen delivered to the client is indicated by the
FIO2 indicator on the ventilator. A sigh is a breath that has a greater volume than
the preset tidal volume.
Strategy:
Use the process of elimination and focus on the subject, tidal volume. Recalling the
definition of this basic respiratory concept will direct you to option 2. If you had
difficulty with this question, review the description of tidal volume.
Reference:
Inc.
Question:
A nurse is reviewing the arterial blood gas analysis results for a client in the
respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, Pa O2 of 86 mm
Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which
of the following?
Options:
1. Normal results
2. Metabolic alkalosis
Answer:
1.
Rationale:
The client s results fall in the normal range for pH (7.35 to 7.45), PaCO2 (35 to 45),
and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than
7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would
be high with respiratory acidosis, whereas bicarbonate levels would be low if
metabolic acidosis was present.
Strategy:
Knowledge related to arterial blood gas analysis is needed to answer this question.
Recalling the normal range for each arterial blood gas level will direct you to option
1. Review these normal values if you had difficulty with this question.
Reference:
(7th ed., p. 117). St. Louis: Mosby.
Inc.
Question:
A nurse in the respiratory care unit is reviewing the laboratory results of a serum
drug level assay for a client receiving theophylline. The nurse determines that a
therapeutic medication level is achieved if which of the following values is noted?
Options:
1. 5 mcg/mL
2. 9 mcg/mL
3. 15 mcg/mL
4. 25 mcg/mL
Answer:
3.
Rationale:
The therapeutic range for serum theophylline (or aminophylline) is 10 to 20
mcg/mL. If the level is below the therapeutic range, the client may experience
frequent exacerbations of the respiratory disorder. If the level is too high, the
medication may need to be stopped or the dose may need to be lowered. Options 1
and 2 indicate low values. Option 4 indicates an elevated value.
Strategy:
Focus on the subject, a therapeutic level. Recalling that this level for theophylline is
10 to 20 mcg / mLwill direct you to option 3. Review this test if you had difficulty
with this question.
Reference:
Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 81).
Question:
A client who is intubated and receiving mechanical ventilation has a nursing
diagnosis of risk for infection. The nurse should avoid doing which of the following in
the care of this client?
Options:
1. Monitor the client s temperature.
2. Monitor sputum characteristics and amounts.
3. Use the closed-system method of suctioning.
4. Drain water from the ventilator tubing into the humidifier bottle.
Answer:
4.
Rationale:
Water in the ventilator tubing should be emptied, not drained back into the
humidifier bottle. This puts the client at risk of acquiring infection, especially
Pseudomonas . Monitoring temperature and sputum production is indicated in the
care of the client. A closed-system method of suctioning does not harm the client
and decreases the risk of infection associated with suctioning.
Strategy:
Use the process of elimination. Note the strategic word avoid and focus on the
subject, infection. Use basic principles related to the prevention of infection to
answer this question. Options 1, 2, and 3 do not place the client at risk for infection.
Review these principles if you had difficulty with the question. Reference:
Inc.
Question:
A physician tells the nurse that a client s chest tube is to be removed. The nurse
brings which of the following dressing materials to the bedside for the physician s
use?
Options:
1. Telfa dressing and neosporin ointment
2. Petrolatum gauze and sterile 4 4 gauze
3. Sterile 4 4 gauze, Neosporin ointment, and tape
4. Benzoin spray and a hydrocolloid dressing
Answer:
2.
Rationale:
On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 4 gauze
is placed at the insertion site. The entire dressing is securely taped to make sure it
is occlusive. The use of Telfa, Neosporin ointment, hydrocolloid dressing, and

benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the
physician as the tape of choice to make the dressing occlusive. Level of Cognitive
Ability - Application
Strategy:
Use the process of elimination and focus on the subject, removal of the chest tube.
Remembering that an occlusive dressing is needed to cover the site will direct you
to the correct option. Review care of a client when a chest tube is removed if you
Reference:
Inc.
Question:
A nurse enters the client s room with a pulse oximetry machine and tells the client
that the physician has ordered continuous oxygen saturation readings. The client s
facial expression changes to one of apprehension. The nurse can quickly and most
effectively alleviate the client s anxiety by stating that pulse oximetry:
Options:
1. Is painless and safe
2. Causes only mild discomfort at the site
3. Requires insertion of only a very small catheter
4. Has an alarm to signal dangerous drops in oxygen saturation levels
Answer:
1.
Rationale:
The nurse should reassure the client that pulse oximetry is a safe, painless,
noninvasive method of monitoring oxygen saturation levels. No discomfort is
involved because the oximeter uses a sensor that is attached to a fingertip, a toe, or
an earlobe. The machine does have an alarm that will sound in response to
interference with monitoring or when the percent of oxygen saturation falls below a
preset level.
Strategy:
Use the process of elimination, focusing on the subject, client anxiety. Option 1 is a
true statement about pulse oximetry and is the option that will relieve anxiety in the
client. Review the procedure for pulse oximetry if you had difficulty with this
question.
Reference:
Question:
A young adult client has never had a chest x-ray examination before and expresses
to the nurse a fear of experiencing some form of harm from the test. Which of the
following statements by the nurse would provide valid reassurance to the client?
Options:
1. You ll wear a lead shield to partially protect your organs from harm.
2. The amount of x-ray exposure is not sufficient to cause DNA damage.
3. The test isn t harmful at all. The most frustrating part is the long wait in
radiology.
4. The x-ray exam itself is painless, and a lead shield protects you from the
minimal radiation. Answer:
4.
Rationale:
Clients should be taught that the amount of exposure to radiation is minimal, and
that the test itself is painless. The wording in each of the other options is only partly
true and therefore cannot provide valid reassurance to the client.
Strategy:
Use the process of elimination, focusing on the dual subject, client fear and
providing reassurance. Use knowledge regarding this basic procedure to direct you
to option 4. Also note the words partially protect , not , and at all in the incorrect
options. Review the procedure and basic information regarding chest radiography if
Reference:
Inc.
Question:
A client has had an arterial blood gas sample drawn from the radial artery, and the
nurse is asked to hold pressure on the site. The nurse should apply pressure for at
least:
Options:
1. 1 minute
2. 2 minutes
3. 5 minutes
4. 10 minutes
Answer:
3.
Rationale:
After blood is drawn for arterial blood gas analysis, continuous pressure must be
applied to the site. A radial artery site requires at least 5 minutes of pressure,
whereas a femoral artery site requires 10 minutes. A small pressure dressing often
is placed on the site after this time period. When the client is receiving
anticoagulant therapy, application of pressure for a longer period of time may be
needed. Level of Cognitive Ability - Application
Strategy:
To answer this question, use knowledge regarding the fundamental concepts related
to the care of the client in whom arterial blood gas samples were drawn.
Remembering that the needle puncture is made into an artery will direct you to
option 3. Review this procedure if you had difficulty with this question. Reference:
Inc.
Question:
A nurse is developing a plan of care for a client at risk for acute respiratory distress
syndrome (ARDS). The nurse includes in the plan of care to assess for early signs of
this disorder by monitoring the client for:
Options:
1. Dyspnea
2. Frothy sputum
4. Edema
Answer:
1.
Rationale:
In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations.
Blood-tinged frothy sputum would present as a later sign after the development of
pulmonary edema. Breath sounds in the early stages of ARDS usually are clear.
Edema is not directly associated with ARDS.
Strategy:
Use the process of elimination. Note the strategic word early in the question. Recall
that in most respiratory disorders, tachypnea, dyspnea, and restlessness are often
the initial presenting signs as the hypoxia develops. This will assist in directing you
to option 1. Review the early signs of ARDS if you had difficulty with this question.
Reference:
Inc.
Question:
The emergency department nurse is monitoring a client who received treatment for
a severe asthma attack. The nurse determines that the client s respiratory status
had worsened if which of the following is noted on assessment?
Options:
2. Wheezing during inhalation
3. Wheezing during exhalation
4. Wheezing throughout the lung fields
Answer:
1.
Rationale:
Wheezing is not a reliable manifestation to determine the severity of an asthma
attack. For wheezing to occur, the client must be able to move sufficient air to
produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma
attack progresses, the client may wheeze during both inspiration and expiration.
Diminished breath sounds may be an indication of severe obstruction and possibly
respiratory failure.

Strategy:
Focus on the subject of the question, worsening of the client's respiratory status.
Use the ABCsairway, breathing, and circulationto assist in directing you to
option 1. Additionally, note the similarity between options 2, 3, and 4. Remember
that diminished breath sounds in a client indicate obstruction and possibly
respiratory failure. Review assessment of a client with an asthma attack if you had
Reference:
Inc.
Question:
A nurse is performing an assessment on a client who was admitted to the hospital
with a diagnosis of carbon monoxide poisoning. Which of the following assessments
performed by the nurse would primarily elicit data related to a deterioration of the
client s condition?
Options:
1. Skin color
2. Apical rate
3. Respiratory rate
4. Level of consciousness
Answer:
4.
Rationale:
The neurological system is primarily affected by carbon monoxide poisoning. With
high levels of carbon monoxide, the neurological status progressively deteriorates.
Although options 1, 2, and 3 would be a component of the assessment of the client
with carbon monoxide poisoning, assessment of the neurological status of the client
would elicit data specific to a deterioration in the client s condition. Level of
Strategy:
Note the strategic word primarily in the question, and use the process of
elimination. Recalling that carbon monoxide depresses the nervous system will
direct you to option 4. Review the effects of carbon monoxide poisoning if you had
Reference:
Inc.
Question:
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who is receiving aminophylline (Theophylline). The nurse monitors the serum
theophylline level and concludes that the medication dosage may need to be
increased if which of the following values is noted?
Options:
1. 5 mg/mL
2. 10 mg/mL
3. 15 mg/mL
4. 20 mg/mL
Answer:
1.
Rationale:
Aminophylline is a bronchodilator. The nurse monitors the theophylline blood serum
level daily when a client is on this medication to ensure that a therapeutic range is
present and to monitor for the potential for toxicity. The therapeutic serum level
range is 10 to 20 mg/mL. If the laboratory result indicated a level of 5 mg/mL, the
dosage of the medication would need to be increased.
Strategy:
Focus on the subject of the question, the need to increase the medication. This
focus and recalling the therapeutic blood serum level will direct you to option 1,
because it is the lowest value in all of the options. Review the therapeutic blood
serum level of theophylline if you had difficulty with this question. Reference:
Gahart, B., & Nazareno, A. (2006). 2006 Intravenous medications (22nd ed., p. 77).
Question:
A nurse caring for a client with a closed chest drainage system notes that the
fluctuation (tidaling) in the water seal compartment has stopped. On the basis of
this assessment finding, the nurse would suspect that:
Options:
1. The chest tubes are obstructed.
2. Suction needs to be increased.
3. The system needs changing.

4. Suction needs to be decreased.
Answer:
1.
Rationale:
Fluid in the water seal compartment should rise with inspiration and fall with
expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the
apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if
the chest drainage tubes are kinked or obstructed. Options 2, 3, and 4 are incorrect
interpretations.
Strategy:
Use the process of elimination. Recalling that tidaling stops when the lung has
reexpanded or if the chest drainage tubes are kinked or obstructed will direct you to
option 1. Review the expected findings in a closed chest drainage system if you had
Reference:
Inc.
Question:
A nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. Which
of the following is the priority intervention before the client is permitted to drink or
eat?
Options:
1. Place the tray in a comfortable position in front of the client.
2. Inflate the cuff on the tracheostomy tube.
3. Deflate the cuff on the tracheostomy tube.
4. Maintain the head of the bed in low Fowler s position.
Answer:
2.
Rationale:
If a client with a tracheostomy is allowed to eat, and the tracheostomy has a cuff,
the nurse should inflate the cuff to prevent aspiration of food or fluids. The head of
the bed should always be elevated; low Fowler s position could lead to aspiration.
The cuff would not be deflated, because of the risk of aspiration. Although the nurse
would ensure that the meal tray is in a comfortable position for the client, this would
not be the priority intervention.

Strategy:
Use the process of elimination and the ABCsairway, breathing, and circulationto
assist in directing you to the correct option. If you had difficulty with this question,
review care of the client with a tracheostomy tube.
Reference:
Inc.
Question:
A nurse has provided discharge instructions to the client who has had a
pneumonectomy. Which statement if made by the client indicates an understanding
of appropriate home care measures? Options:
1. I should restrict my fluid intake for 2 weeks.
2. If I experience any soreness in my chest or shoulder, I should notify the
physician.
3. I should perform arm exercises two or three times a day.
4. If I experience any numbness or altered sensation around the incision, I should
contact the physician.
Answer:
3.
Rationale:
The client should be instructed to perform arm and shoulder exercises two or three
times a day. The client is told to expect soreness in the chest and shoulder and an
altered feeling of sensation around the incision site for several weeks. It is not
necessary to contact the physician if these symptoms occur. The client is
encouraged to drink liquids to liquefy secretions, making them easier to
expectorate. Level of Cognitive Ability - Analysis
Strategy:
Note the strategic words indicates an understanding . Use the process of
elimination, focusing on the anatomical location of the surgical site and the
complications that can follow the pneumonectomy. If you had difficulty with this
question, review client teaching points after pneumonectomy.
Reference:

Inc.
Question:
A nurse is providing discharge instructions to the client who has had a
pneumonectomy and prepares a list of postoperative instructions for the client.
Which of the following would the nurse include in the list? Options:
1. Avoid lifting any objects greater than 30 pounds for at least 3 weeks.
2. Avoid breathing exercises to allow the diaphragm to strengthen.
3. Contact the physician if any feelings of weakness and fatigue occur.
4. Report any signs of respiratory infection to the physician.
Answer:
4.
Rationale:
After a pneumonectomy, the client should be instructed to avoid heavy lifting of any
objects more that 20 pounds until the muscles of the chest wall have healed
completely, which takes about 3 to 6 months. The client also is instructed to
perform breathing exercises for the first 3 weeks at home and to space activities to
allow for frequent rest periods. The client should be told to expect feelings of
weakness and fatigue for the first 3 weeks after surgery. If any signs of respiratory
infection occur, the physician should be notified.
Strategy:
Use the process of elimination and general principles related to postoperative care
to assist in directing you to option 4. Additionally, focus on the anatomical location
of the surgical site to direct you to the correct option. If you had difficulty with this
question, review client teaching points after a pneumonectomy.
Reference:
Inc.
Question:
A client has been treated for pleural effusion with a thoracentesis. The nurse
determines that this procedure has been effective if the client has:
Options:
1. Decreased severity of cough
2. Absence of dyspnea
3. Decreased tactile fremitus
4. Dull percussion notes
Answer:
2.
Rationale:
The client who has undergone thoracentesis should experience relief of the signs
and symptoms experienced before the procedure. Typical signs and symptoms of
pleural effusion include dry, nonproductive cough, dyspnea (usually on exertion),
decreased or absent tactile fremitus, and dull or flat percussion notes on respiratory
assessment.
Strategy:
Use the process of elimination and note the strategic word effective . A dull
percussion note over lung tissue is abnormal and is eliminated first. Because
options 1 and 3 specify a decreased symptom, they do not demonstrate that the
thoracentesis has been completely effective so they also are eliminated. This leaves
option 2, absence of dyspnea, as the correct option. The client should be free of
dyspnea after this procedure. Review pleural effusion and the expected effects of a
thoracentesis if you had difficulty with this question.
Reference:
Inc.
Question:
A client did not seek medical treatment for a previous respiratory infection, and
subsequently an empyema developed in the left lung. The nurse assesses the client
for which of the following signs and symptoms associated with this problem?
Options:
1. Pleural pain and fever
2. Hyperresonant breath sounds over the left thorax
3. Decreased respiratory rate
4. Diaphoresis during the day
Answer:
1.
Rationale:
The client with empyema usually experiences dyspnea, pleural pain, night sweats,
fever, anorexia, and weight loss. There is a decrease in breath sounds over the
affected area, a flat sound to percussion, and decreased tactile fremitus.
Strategy:
Use the process of elimination. Recalling that empyema results from an infectious
process will direct you to the option that contains fever and pleural pain. If you are
unfamiliar with the assessment signs associated with this condition, review this
content.
Reference:
Inc.
Question:
A client with long-standing empyema undergoes decortication of the affected lung
area. Postoperatively, the nurse places the client in which position?
Options:
1. Supine
2. Sims
3. Side-lying
4. Semi-Fowler s
Answer:
4.
Rationale:
After any procedure involving thoracotomy, the nurse positions the client in semiFowler s position. This position allows for maximal lung expansion and promotes
drainage through chest tubes that may be placed during surgery.
Strategy:
Use the process of elimination. Eliminate options 1, 2, and 3 because they are
comparative or alike. Also, recall that after thoracic surgery, the client needs to be
upright for ease of breathing. Review postoperative care after this procedure if you
Reference:

Inc.
Question:
A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube
in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH
is 4.5. Based on this finding, which of the following nursing actions would be
appropriate?
Options:
2. Reassess the pH in 4 hours.
3. Instill 30 mL of sterile water.
4. Administer a dose as needed of a prescribed antacid.
Answer:
4.
Rationale:
The client on a mechanical ventilator who has a nasogastric tube in place should
have the gastric pH monitored at the beginning of the shift or least every 12 hours.
Because of the risk of stress ulcer formation, a pH of less than 5 should be treated
with prescribed antacids. If there is no order for the antacid, the physician should be
notified.
Strategy:
Focus on the subject, a pH of 4.5. Recalling that the normal body pH and that the
client is at risk for stress ulcer formation will direct you to option 4. If you had
difficulty with this question, review the expected pH value and the associated
nursing actions.
Reference:
Mosby.
Inc.
Question:
A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on
the ventilator sounds. The nurse suspects that the most likely cause of the alarm is
which of the following? Options:

2. An exaggerated client inspiratory effort
3. Generation of extreme negative pressure by the client
4. Accumulation of respiratory secretions
Answer:
4.
Rationale:
The high pressure alarm sounds when the preset peak inspiratory pressure limit is
reached by the ventilator before it has delivered a set tidal volume. Causes include
tubing obstruction or kinks, breathing out of phase or bucking the ventilator,
accumulation of secretions, condensation of water in the ventilator tubing,
coughing or Valsalva maneuvers, increased airway resistance, bronchospasms,
decreased pulmonary compliance, and pneumothorax. Options 1, 2, and 3 identify
causes for triggering the low-pressure alarm.
Strategy:
Use the process of elimination and note the strategic words high-pressure alarm .
Think about the physiology associated with high pressure to assist in directing you
to option 4. If you had difficulty with this question, review the causes for triggering
ventilator alarms.
Reference:
Inc.
Question:
A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on
the ventilator sounds. The nurse suspects that the most likely cause of the alarm is
which of the following? Options:
2. An exaggerated client inspiratory effort
3. Generation of extreme negative pressure by the client
4. Accumulation of respiratory secretions
Answer:
4.
Rationale:
The high pressure alarm sounds when the preset peak inspiratory pressure limit is
reached by the ventilator before it has delivered a set tidal volume. Causes include
tubing obstruction or kinks, breathing out of phase or bucking the ventilator,
accumulation of secretions, condensation of water in the ventilator tubing,

coughing or Valsalva maneuvers, increased airway resistance, bronchospasms,
decreased pulmonary compliance, and pneumothorax. Options 1, 2, and 3 identify
causes for triggering the low-pressure alarm.
Strategy:
Use the process of elimination and note the strategic words high-pressure alarm .
Think about the physiology associated with high pressure to assist in directing you
to option 4. If you had difficulty with this question, review the causes for triggering
ventilator alarms.
Reference:
Inc.
Question:
A nurse is caring for a client on a mechanical ventilator. The low-pressure alarm
sounds. The nurse suspects that which of the following is the underlying cause for
triggering this alarm?
Options:
1. A tubing obstruction or kink
2. The accumulation of secretions
3. Condensation of water in the ventilator tubing
4. Disconnection of the ventilator tubing
Answer:
4.
Rationale:
The low-pressure alarm sounds when little or no pressure is generated during the
delivery of the machine breaths. Alarm triggers include disconnection of the
ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client
respiratory effort generating extreme negative pressure. Options 1, 2, and 3 identify
causes for triggering the high-pressure alarm.
Strategy:
Use the process of elimination and note the strategic words low-pressure alarm .
Thinking about the concepts of low pressure will assist in directing you to option 4. If
you had difficulty with this question, review the causes for triggering a low-pressure
alarm on a mechanical ventilator.
Reference:
Inc.
Question:
A nurse is caring for a client with a chest tube drainage system. While the client is
being assisted to sit up in bed in preparation for ambulation, the chest drainage
system accidentally disconnects. The initial nursing action is which of the following?
Options:
1. Place the end of the chest tube in a container of sterile water.
2. Contact the physician.
3. Call a respiratory therapist.
4. Encourage the client to perform the Valsalva maneuver.
Answer:
1.
Rationale:
If a chest tube becomes disconnected, the nurse should as quickly as possible place
the end of the tube in a container of sterile water or saline until the drainage
system can be replaced. It may be necessary to contact the physician, but this
would not be the initial nursing action. It is not necessary to contact a respiratory
therapist at this time. Asking the client to perform a Valsalva maneuver is not
appropriate. Level of Cognitive Ability - Application
Strategy:
Use the process of elimination. Focus on the physiology of the chest tube drainage
system to answer this question. Recalling that maintaining the underwater seal
drainage is essential will assist in directing you to the correct option. If you had
difficulty with this question, review care of the client with a closed chest tube
drainage system.
Reference:
Inc.
Question:
A nurse is caring for a client with a chest tube drainage system. During
repositioning of the client, the chest tube accidentally pulls out of the pleural cavity.
The initial nursing action is which of the following? Options:
2. Contact the respiratory therapist.
3. Apply an occlusive dressing.
4. Reinsert the chest tube quickly.
Answer:
3.
Rationale:
If a chest tube is accidentally pulled out, the nurse would immediately apply an
occlusive dressing and then contact the physician. The physician needs to be
notified, but this is not the initial nursing action. It is not necessary to contact the
respiratory therapist. It is not appropriate and not a nursing role to reinsert a chest
tube.
Strategy:
Note the strategic word initial in the question. Focus on the information provided in
the question to direct you to option 3. If you had difficulty with this question or are
unfamiliar with the care of a client with a chest tube, review this content.
Reference:
Elsevier Inc.
Question:
A client who experiences frequent upper respiratory infections (URIs) asks the nurse
why food doesn t seem to have any taste during illness. In formulating a response,
the nurse understands that this is due to which of the following?
Options:
1. Anorexia, triggered by the infectious organism
2. Blocked nasal passages that impair the sense of smell
3. Lack of client energy to cook wholesome meals
4. Infection, which blocks sensation in the taste buds of the tongue
Answer:
2.
Rationale:
When nasal passages become blocked as a result of a URI, the client has an
impaired sense of taste and smell. This occurs because one of the normal functions
of the nose is to stimulate appetite through the sense of smell. The other options
are incorrect.
Strategy:
Use the process of elimination noting the strategic words doesn t seem to have any
taste . Recalling the function of the nose and its adjunct role in the sense of taste
will direct you to option 2. If this question was difficult for you, review the anatomy
and physiology related to the sense of smell and taste. Reference:
Inc.
Question:
A registered nurse who is orienting a new nursing graduate to the hospital
emergency department instructs the new graduate to monitor a client for one-sided
chest movement on the right side while the client is being intubated by the
physician. The nursing graduate determines that this instruction is based on the
understanding that the endotracheal tube could enter the:
Options:
1. Right main bronchus if inserted too far
2. Left main bronchus if inserted too far
3. Right main bronchus if not inserted far enough
4. Left main bronchus if not inserted far enough
Answer:
1.
Rationale:
If the endotracheal tube is inserted too far into the client s trachea, the tube will
travel down and enter the right main bronchus. This occurs because the right
bronchus is shorter and wider than the left and extends downward in a more vertical
plane. If the tube is not inserted far enough, no chest expansion at all will occur. The
other options are incorrect.
Strategy:
Use the process of elimination. Eliminate options 3 and 4 first because if the tube
was not inserted far enough, no chest expansion would occur at all. Regarding the
remaining options, noting the strategic word right in the question will direct you to
the correct option. Review the complications associated with intubation if you had
Reference:
Mosby.
Inc.
Question:
A nurse is reinforcing instructions to a client for use of an incentive spirometer. The
nurse tells the client to sustain the inhaled breath for 3 seconds. When the client
asks the nurse about the rationale for this action, the nurse explains that the
primary benefit is to:
Options:
1. Dilate the major bronchi
2. Increase surfactant production
3. Enhance ciliary action in the tracheobronchial tree
4. Maintain inflation of the alveoli
Answer:
4.
Rationale:
Sustained inhalation helps maintain inflation of the terminal bronchioles and alveoli,
thereby promoting better gas exchange. Routine use of devices such as an incentive
spirometer can help prevent atelectasis and pneumonia in clients at risk. Options 1,
2, and 3 are incorrect.
Strategy:
Use the process of elimination focusing on the subject, the benefit of sustaining the
inhaled breath. Recalling that the alveoli are the most distal part of the respiratory
tree will direct you to option 4. Review the benefit of the incentive spirometer if you
Reference:
Inc.
Question:
A client with chronic obstructive pulmonary disease (COPD) who is beginning
oxygen therapy asks the nurse why the flow rate cannot be increased to more than
2 to 3 L/min. The nurse responds that this would be harmful because a higher
oxygen flow rate could:
Options:
1. Increase the risk of pneumonia from drier air passages
2. Lead to drying of nasal passages
3. Decrease the client s oxygen-based respiratory drive
4. Decrease the client s carbon dioxidebased respiratory drive
Answer:
3.
Rationale:
Normally, respiratory rate varies with the amount of carbon dioxide present in the
blood. In clients with COPD, this natural center becomes ineffective after exposure
to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen
provides the respiratory stimulus. The client with COPD cannot increase oxygen flow
rate levels independently because a higher oxygen level could obliterate the
respiratory drive, leading to respiratory failure. Options 1, 2, and 4 are incorrect.
Strategy:
Use knowledge of basic respiratory physiology and note that the client has COPD.
Recalling the importance of oxygen and carbon dioxide tensions in the bloodstream
and their relationship to COPD will direct you to option 3. Review care of the client
with COPD if you had difficulty with this question. Reference:
Inc.
Question:
A client who is experiencing respiratory difficulty asks the nurse, Why it is so much
easier to breathe out than in? In providing a response, the nurse explains that
breathing is easier on exhalation because: Options:
1. The respiratory muscles contract.
2. The respiratory muscles relax.
3. Air flows by gravity.
4. Air is flowing against a pressure gradient.
Answer:
2.
Rationale:
Exhalation is less taxing for the client because it is a passive process in which the
respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows
according to a pressure gradient from higher pressure to lower pressure. It does not
flow against a pressure gradient.
Strategy:
Use the process of elimination. Recalling that air flows according to a pressure
gradient allows you to eliminate options 3 and 4. Choose correctly between the
remaining options based on your knowledge that respiratory muscles tighten or
contract with inspiration. Review the physiology of the respiratory system if you had
Reference:
Mosby.
Inc.
Question:
A client who has been diagnosed with pleurisy tells the nurse that it is painful to
inhale. The nurse responds that this is an expected finding because:
Options:
1. The inflamed pleura cannot glide against each other as they normally do.
2. This condition causes nerve endings to be especially sensitive.
3. The stretch receptors in the lungs are irritated.
4. The diaphragm is weak and is difficult to move.
Answer:
1.
Rationale:
Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation
prevents the parietal and visceral pleural surfaces from gliding over each other with
respiration. As a result, the client experiences pain, especially with inspiration.
Options 2, 3, and 4 are incorrect.
Strategy:
Use the process of elimination. Note that pleurisy refers to the pleura . The only
option that addresses this anatomical area is option 1. If this question was difficult
for you, review the underlying pathophysiology for pleurisy.
Reference:
Mosby.
Inc.
Question:
A client with iron deficiency anemia complains of feeling fatigued almost all of the
time. The nurse tells the client that this an expected symptom because:
Options:
1. Blood flows more slowly when the hemoglobin or hematocrit is low.
2. Adequate amounts of hemoglobin are needed to carry oxygen for tissue
metabolism.
3. The work of breathing is increased when the client is anemic.
4. The body has to work harder to fight infection with anemia.
Answer:
2.
Rationale:
Oxygen is needed to meet the metabolic needs of the body. With decreased
hemoglobin, such as in iron deficiency anemia, oxygen-carrying capacity of the
blood is less than normal. The client feels the effect of this change as fatigue.
Options 1, 3, and 4 are incorrect.
Strategy:
Use the process of elimination. Recalling that hemoglobin transports most of the
oxygen needed for cellular respiration will direct you to option 2. Review the
pathophysiological features of anemia if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse who is participating in a client care conference with other members of the
health care team is discussing the condition of a client with acute respiratory
distress syndrome (ARDS). The physician states that as a result of fluid in the
alveoli, surfactant production is falling. The nurse interprets that the natural
consequence of insufficient surfactant is:
Options:
1. Collapse of alveoli and decreased compliance
2. Bronchoconstriction and stridor
3. Decreased ciliary action and retained secretions
4. Atelectasis and viral infection
Answer:
1.
Rationale:
Surfactant is a phospholipid produced in the lungs that decreases surface tension in
the lungs. This prevents the alveoli from sticking together and collapsing at the end
of exhalation. When alveoli collapse, the lungs become stiff because of decreased
compliance. Common causes of decreased surfactant production are ARDS and
atelectasis. Options 2, 3, and 4 are incorrect.
Strategy:
Note the strategic words natural consequence and insufficient surfactant . Recalling
the underlying pathophysiology for ARDS will direct you to option 1. Review the
physiology of ARDS if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) due
to respiratory disease. The nurse anticipates that as the client s CO2 level rises, the
pH should:
Options:
1. Rise
2. Fall
3. Remain unchanged
4. Double
Answer:
2.
Rationale:
CO2 acts as an acid in the body. Therefore, with a rise in CO2, a corresponding fall in
pH occurs. This concept forms the basis for key aspects of acid-base balance. The
other options are incorrect. Level of Cognitive Ability - Analysis
Strategy:
Note the strategic words retaining CO2 and focus on the client s diagnosis.
Recalling the inverse relationship between pH and CO2 in the body will direct you to
option 2. As CO2 rises, pH falls, and as CO2 falls, pH rises. Review the concepts
related to acid-base balance in respiratory disease if you had difficulty with this
question.
Reference:
Mosby.
Inc.
Question:
A nurse reads in the progress notes for a client with pneumonia that areas of the
client s lungs are being perfused but are not being ventilated. The nurse interprets
this occurrence as the presence of: Options:
1. Anatomical dead space
2. Physiological dead space
3. Shunting
4. Ventilation-perfusion matching
Answer:
3.
Rationale:
Shunting occurs when a portion of the lung area has adequate capillary perfusion
but is not being ventilated. As a result, no gas exchange occurs. Anatomical dead
space normally is present in the conducting airways, where pulmonary capillaries
are absent. Physiological dead space occurs with conditions such as emphysema
and pulmonary embolism. Ventilation-perfusion matching refers to a matching
distribution of blood flow in the pulmonary capillaries and air exchange in the
alveolar units of the lungs.

Strategy:
Use the process of elimination and knowledge of the common terms used in
describing respiratory physiology. Remember that shunting occurs when a portion of
the lung area has adequate capillary perfusion but is not being ventilated. If this
question was difficult for you, review these fundamental concepts.
Reference:
Inc.
Question:
A nurse is monitoring the status of the client who is being treated for dyspnea. The
nurse is aware that which of the following factors will decrease the work of
breathing for this client?
Options:
1. Increased mucus production
2. Interstitial pulmonary edema
3. Increased airway resistance
4. Bronchodilation
Answer:
4.
Rationale:
Bronchodilation decreases the airway resistance and decreases the work of
breathing for the client. Clients with dyspnea who have increased mucus
production, edema, or bronchospasm exhibit increased airway resistance, which
increase the work of breathing.
Strategy:
Use the process of elimination, focusing on the subject, decrease the work of
breathing. Recall the various factors that enhance or inhibit respiratory processes.
The correct option is the only one that allows air to enter the lungs and perfuse the
pulmonary capillaries. Review the physiology of the respiratory system if you had
Reference:
positive outcomes (7th ed.), pp. 493-494. Philadelphia: W.B. Saunders.

Inc.
Question:
A nurse is reinforcing instructions to a client about diaphragmatic breathing. The
nurse tells the client that this technique is helpful because, in normal respiration, as
the diaphragm contracts, it: Options:
1. Moves downward and out
2. Moves up and inward
3. Makes the thoracic cage smaller
4. Aids in exhalation
Answer:
1.
Rationale:
As the diaphragm contracts, it moves downward and out, becoming flatter and
expanding the thoracic cage, to promote lung expansion. This process occurs during
the inspiratory phase of the respiratory cycle. The incorrect options occur with
exhalation and relaxation of the diaphragm.
Strategy:
Use the process of elimination. Visualize the respiratory process and the contraction
of the diaphragm to direct you to option 1. Review the respiratory process and the
occurrence of diaphramatic contraction and relaxation if you had difficulty with this
question.
Reference:
Mosby.
Inc.
Question:
A nurse is reading the report for a chest x-ray study in a client who has just been
intubated. The report states that the tip of the endotracheal tube lies 1 cm above
the carina. The nurse interprets that the tube is positioned above:
Options:
1. The point at which the larynx connects to the trachea

2. The area connecting the oropharynx to the laryngopharynx
3. The bifurcation of the right and left main bronchi
4. The first tracheal cartilaginous ring
Answer:
3.
Rationale:
The carina is a cartilaginous ridge that separates the openings of the two main
(right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube
will enter the right main bronchus as a result of the natural curvature of the airway.
This is hazardous because then only the right lung will be ventilated. Incorrect tube
placement is easily detected, because only the right lung will have breath sounds
and rise and fall with ventilation. Options 1, 2, and 4 are incorrect interpretations.
Strategy:
Use the process of elimination. Visualizing the anatomy of the respiratory system
will direct you to option 3. Review the anatomy of the respiratory system if you had
Reference:
Inc.
Question:
A nurse is told that a client will have an arterial blood gas sample drawn on room
air. The nurse is asked to complete the laboratory requisition. The nurse documents
on the requisition that the client was receiving how much oxygen for the procedure?
Options:
1. 16%
2. 21%
3. 30%
4. 40%
Answer:
2.
Rationale:
Room air contains 21% oxygen. It is not possible to give a client 16% oxygen
because it is less than room air. Options 3 and 4 specify oxygen amounts that
commonly are used to supplement clients experiencing respiratory difficulty.

Integrated Process - Communication and Documentation
Strategy:
Focus on the strategic words room air . Recalling that room air contains 21% oxygen
will direct you to option 2. Review the content for oxygen therapy if you had
Reference:
Perry, A., & Potter, P. (2006). Clinical nursing skills and techniques (6th ed., p. 768).
Question:
A chest x-ray report states that the client has a left apical pneumothorax. The nurse
caring for this client monitors the status of breath sounds in that area by placing the
stethoscope:
Options:
1. Posteriorly under the left scapula
2. Just under the left clavicle
3. In the fifth intercostal space
4. Near the lateral twelfth rib
Answer:
2.
Rationale:
The nurse would place the stethoscope just under the left clavicle. The apex of the
lung is the rounded, uppermost part of the lung. The other options are incorrect.
Strategy:
Use the process of elimination. Focusing on the strategic words left apical
pneumothorax and visualizing the anatomy of the respiratory system will direct you
to option 2. Review the anatomy of the respiratory system if you had difficulty with
this question.
Reference:
Inc.
Question:
A nurse is teaching a client with pulmonary disease about fundamental concepts of
gas exchange. When requested for further details by the client, the nurse explains
that gas exchange occurs through a process called:
Options:
1. Diffusion
2. Osmosis
3. Active transport
4. Ionization
Answer:
1.
Rationale:
Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide
move across the alveolar-capillary membrane as a result of a pressure gradient.
Osmosis is the process of movement according to a concentration gradient. Active
transport is movement of molecules by carrying them across a cell membrane.
Ionization refers to the process whereby a molecule gains or loses electrons. Level
of Cognitive Ability - Application
Strategy:
Focus on the subject, the occurrence of gas exchange. Recalling the process of
respiration and the movement of gases across the alveolar-capillary membrane will
direct you to option 1. Review these definitions related to the respiratory process if
Reference:
Inc.
Question:
A nurse is caring for a client who has just returned from the post-anesthesia care
unit after radical neck dissection. The nurse assesses the type of drainage from the
wound for which of the following characteristics as expected in the immediate
postoperative period?
Options:
1. Serosanguineous
2. Grossly bloody
3. Serous
4. Serous with sputum

Answer:
1.
Rationale:
Immediately after radical neck dissection, the client will have a wound drain in the
neck attached to portable suction, which drains serosanguineous fluid. In the first
24 hours after surgery, the drainage may total 80 to 120 mL. Options 2, 3, and 4 are
not expected findings.
Strategy:
Note the strategic words immediate postoperative period . Because the wound
suction tube does not sit in the airway, option 4 is eliminated. Because serous
drainage contains no blood, this is not likely to be noted in the immediate
postoperative period. Knowing that grossly bloody drainage indicates bleeding or
hemorrhage will direct you to option 1 from the remaining options. Review normal
expected assessment findings after radical neck dissection if you had difficulty with
this question.
Reference:
for collaborative care (5th ed., pp. 345-346, 575). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse has provided instructions for the client with tuberculosis (TB) instructions on
proper handling and disposal of respiratory secretions. The nurse determines that
the client demonstrates understanding of the instructions by stating:
Options:
1. I need to wash my hands at least four times a day.
2. I will turn my head to the side if I need to cough or sneeze.
3. I will discard used tissues in a plastic bag.
4. I will brush my teeth and rinse my mouth once a day.
Answer:
3.
Rationale:
The client with TB should wash hands carefully after each contact with respiratory
secretions. The client should cover the mouth and nose when laughing, sneezing, or
coughing. Used tissues are discarded in a plastic bag. Oral care is done as for any
other client.
Strategy:
Focus on the subject of the question. Note that the question specifically asks for
information about handling and disposal of secretions. The only option that
addresses this subject is option 3. Review home care instructions for the client with
TB if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is caring for a client who had a Mantoux skin test 48 hours ago on
admission to the nursing unit. The nurse reads the test result as positive. Which
action by the nurse has the highest priority? Options:
2. Call the radiology department for a chest x-ray study to be done.
3. Document the finding in the client s record.
4. Call the employee health service department.
Answer:
1.
Rationale:
The nurse who obtains a positive Mantoux test reading calls the physician
immediately. The physician would order a chest x-ray study to rule out whether the
client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture
would be obtained to confirm the diagnosis of active TB. The client can be placed on
TB precautions prophylactically until a final diagnosis is made. Although the results
of the test would be documented and the employee health service department
would be notified, these are not the actions of highest priority from the options
provided.
Strategy:
Note the strategic words highest priority . Because the nurse cannot order
diagnostic tests, eliminate option 2 first. Likewise, option 4 can be eliminated,
because calling the employee health service is of no benefit to the client. Regarding
the remaining options, notifying the physician should have a higher priority than the
documentation, even though they may both be done in the same narrow time
period. Review the implications related to a positive Mantoux test result if you had
difficulty with this question. Reference:
Inc.
Question:
A client has a chest tube attached to a Pleur-Evac drainage system. As part of
routine nursing care, the nurse would ensure that:
Options:
1. The connection between the chest tube and the drainage system is taped, and an
occlusive dressing is maintained at the insertion site.
2. The amount of drainage into the chest tube is noted and recorded every 24 hours
in the client s record.
3. The suction control chamber has sterile water added every shift, and the system
is kept below waist level.
4. The water seal chamber has continuous bubbling, and assessment for crepitus is
done once a shift. Answer:
1.
Rationale:
The nurse ensures that all system connections are securely taped to prevent
accidental disconnection and that an occlusive dressing is maintained at the chest
tube insertion site. Drainage is noted and recorded every hour in the first 24 hours
after insertion and every 8 hours thereafter. The system is kept below the level of
the waist. Assessment for crepitus is done once every 8 hours. Sterile water is
added to the suction control chamber only as needed to replace evaporation losses.
Continuous bubbling in the water seal chamber indicates an air leak in the system
and requires immediate investigation and correction.
Strategy:
Note that each option has two parts. In order for the option to be correct, both parts
of the answer must be correct. Knowing this, eliminate options 3 and 4 first. Water
needs to be added only as needed, and there should not be continuous bubbling in
the water seal. Regarding the remaining options, recalling that chest tube
assessment is done at least every 8 hours directs you to option 1. Review the
assessment measures required in the care of a client with a chest tube if you had
Reference:
Mosby.
Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp. 1121, 1171). St.
Question:
A nurse is planning care for a client scheduled for a tracheostomy procedure. What
equipment should the nurse plan to have at the bedside when the client returns
from surgery?
Options:
1. Oral airway
2. Epinephrine (Adrenalin)
3. Obturator
4. Tracheostomy set with the next larger size
Answer:
3.
Rationale:
A replacement tube of the same size and an obturator are kept at the bedside at all
times in case the tracheostomy tube is dislodged. Additionally, 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.
Strategy:
Use the process of elimination. Eliminate option 4 first because a tracheostomy set
of the next larger size would not be appropriate for the client. Next, eliminate option
2 because it is unrelated to the subject of the question. Regarding the remaining
options, recall that the airway has been altered because of the tracheostomy, so an
oral airway would not be necessary. Also recall that a replacement tube and an
obturator should be kept at the bedside of a client with a tracheostomy, along with
a curved hemostat, at all times. Review care of the client with a tracheostomy if you
Reference:
Inc.
Question:
A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The
high-pressure alarm sounds on the ventilator. The nurse plans to:
Options:
1. Assess for a disconnection.
2. Evaluate the cuff for a leak.
3. Notify the respiratory therapist.
4. Suction the client.
Answer:
4.
Rationale:
When the high-pressure alarm sounds on a ventilator, it is most likely due to an
obstruction. The obstruction can be caused by the client biting on the tube, kinking
of the tubing, or mucus plugging requiring suctioning. Options 1 and 2 would cause
the low-pressure alarm to sound. Option 3 delays necessary treatment.
Strategy:
Use the process of elimination. Note the strategic words high-pressure alarm in the
question. Recalling that that the high-pressure alarm indicates a possible
obstruction will assist in directing you to the correct option. Review nursing
interventions related to care of a client on a ventilator if you had difficulty with this
question.
Reference:
Inc.
Question:
A nurse is caring for a client with a chest tube drainage system. The nurse notes a
fluctuating water level on inspiration and expiration in the submerged tube in the
water seal chamber of the chest tube system. Which nursing action is appropriate?
Options:
2. Encourage coughing and deep breathing.
4. Increase the suction.
Answer:
1.
Rationale:
With normal breathing, the water level rises with inspiration and falls with
expiration. The oppositethe level falls with inspiration and rises with expiration
occurs when the client is on positive-pressure mechanical ventilation. This is an
expected normal occurrence in a chest tube drainage system; therefore, no action is
necessary except to document the findings.
Strategy:
Use the process of elimination. Recalling that a fluctuating water level is expected in
the water seal chamber will assist in directing you to option 1. Review chest tube
drainage systems if you had difficulty with this question.
Reference:
Elsevier Inc.
Question:
A nurse is caring for a client with a chest tube drainage system. The nurse notes a
fluctuating water level on inspiration and expiration in the submerged tube in the
water seal chamber of the chest tube system. Which nursing action is appropriate?
Options:
2. Encourage coughing and deep breathing.
4. Increase the suction.
Answer:
1.
Rationale:
With normal breathing, the water level rises with inspiration and falls with
expiration. The oppositethe level falls with inspiration and rises with expiration
occurs when the client is on positive-pressure mechanical ventilation. This is an
expected normal occurrence in a chest tube drainage system; therefore, no action is
necessary except to document the findings.
Strategy:
Use the process of elimination. Recalling that a fluctuating water level is expected in
the water seal chamber will assist in directing you to option 1. Review chest tube
drainage systems if you had difficulty with this question.
Reference:
Elsevier Inc.
Question:
A nurse is caring for a client with a chest tube drainage system and notes constant
bubbling in the water seal chamber. Which of the following nursing actions is
appropriate?
Options:
1. Reposition the client.
2. Change the chest tube drainage system.
3. Notify the physician.
4. No action is necessary because this is a normal expected finding.
Answer:
3.
Rationale:
Constant bubbling occurring in the water seal chamber may indicate a leak in the
system. Among the options provided, the appropriate action is to notify the
physician. Options 1, 2, and 4 are incorrect. Level of Cognitive Ability - Analysis
Strategy:
Note the strategic words constant bubbling in the water seal chamber and visualize
the operation of this drainage system. Knowing that this is an unexpected
occurrence and may indicate a potential complication with the chest tube drainage
system will assist in directing you to option 3. If you had difficulty with this question
or are unfamiliar with care of the chest tube drainage system, review this content
area.
Reference:
Elsevier Inc.
Question:
A nurse in an ambulatory clinic is preparing to administer a Mantoux test to a client
who may have been exposed to a person with tuberculosis (TB). The client reports
having received the bacille Calmette- Gurin (bCG) vaccine before moving to the
United States from a foreign country. The nurse interprets that:

Options:
1. The client s test result will be negative, and a sputum culture will be required for
diagnosis. 2. The client s test result will be positive, and a chest x-ray study will be
required for evaluation. 3. The client has no risk of acquiring TB and needs no
further workup.
4. The client is at increased risk of acquiring TB and needs immediate medication
therapy. Answer:
2.
Rationale:
BCG vaccine is routinely given in many foreign countries to enhance resistance to
TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in
persons who have received the vaccine will always be positive. This client needs to
be evaluated for TB with a chest x-ray study. Options 1, 3, and 4 are incorrect
interpretations.
Strategy:
Use the process of elimination. Recalling that the BCG vaccine contains attenuated
tubercle bacilli will direct you to option 2. Review the characteristics of this vaccine
if you had difficulty with this question. Reference:
Inc.
Question:
A nurse is caring for a client who is receiving feedings by nasogastric tube. The
client suddenly begins to vomit, and the nurse quickly repositions the client. The
client is coughing and having difficulty breathing, and the nurse suspects that the
client has aspirated the feeding. What is the nurse s next action? Options:
2. Call a code.
4. Check the client s vital signs.
Answer:
3.
Rationale:
If the client aspirates the feeding, the nurse would suction the client s airway. The
client s respiratory status would be monitored closely until a normal respiratory

pattern resumed. Although the physician may need to be notified, ensuring a patent
airway is the priority. The question presents no data indicating the need to call a
code. The client s vital signs may need to be monitored, but this is not the priority
action.
Strategy:
Focus on the information provided in the question and note the strategic word next .
Use the ABCsairway, breathing, and circulation. If a client aspirates a feeding,
suctioning is necessary to provide a patent airway. Review care of the client
receiving tube feedings if you had difficulty with this question.
Reference:
for collaborative care (5th ed., pp. 578-579, 1431-1432). Philadelphia: W.B.
Saunders.
Mosby.
Inc.
Question:
A nurse is preparing to check the breath sounds of a client. When auscultating for
bronchovesicular breath sounds, the nurse would place the stethoscope over:
Options:
1. The peripheral lung fields
2. The major bronchi
3. The trachea and larynx
4. The lower posterior thorax
Answer:
2.
Rationale:
Bronchovesicular breath sounds are heard over major bronchi. Vesicular breath
sounds are heard over the peripheral lung fields. Bronchial (tracheal) breath sounds
are heard over the trachea and larynx. The upper sternum area is where major
bronchi are located.
Strategy:
Use the process of elimination. Eliminate options 1 and 4 first because these
locations are comparative or alike. Regarding the remaining options, recalling that
bronchovesicular breath sounds are heard over major bronchi will direct you to
option 2. Review the locations for auscultating normal breath sounds if you had
Reference:
Jarvis, C. (2004). Physical examination and health assessment (4th ed., pp. 454456). Philadelphia: W.B. Saunders.
Inc.
Question:
A client who experiences frequent upper respiratory infections (URIs) asks the nurse
why food doesn t seem to have any taste during illness. In formulating a response,
the nurse understands that this is due to which of the following?
Options:
1. Anorexia is triggered by the infectious organism.
2. Blocked nasal passages impair the senses of smell and taste.
3. The client does not have enough energy to cook wholesome meals.
4. The infection blocks sensation from the taste buds of the tongue.
Answer:
2.
Rationale:
When nasal passages become blocked as a result of a URI, the client s senses of
taste and smell are impaired. This occurs because one of the normal functions of
the nose is to stimulate appetite through the senses of smell and its adjunct role in
the sense of taste. The other options are incorrect. Level of Cognitive Ability Comprehension
Strategy:
To answer this question accurately, recall the functions of the nose. Noting the
words doesn t seem to have any taste will assist in directing you to option 2.
Review the anatomy and physiology of the respiratory system if you had difficulty
with this question.
Reference:
for collaborative care (5th ed., pp. 524, 604, 607). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse who is orienting another nurse to the hospital emergency department
instructs the orientee to assess for one-sided chest movement on the right while a
client is being intubated by the physician. The nurse s instruction is based on the
possibility that the endotracheal tube could inadvertently enter the: Options:
1. Right main bronchus if inserted too far
2. Left main bronchus if inserted too far
3. Right main bronchus if not inserted far enough
4. Left main bronchus if not inserted far enough
Answer:
1.
Rationale:
If the endotracheal tube is inserted too far into the client s trachea, the tube will
travel down and enter the right main bronchus. This occurs because the right
bronchus is shorter and wider than the left and extends downward in a more vertical
plane. The other options are incorrect.
Strategy:
Use the process of elimination. Eliminate options 3 and 4 first because if the tube
was not inserted far enough, no chest expansion would occur at all. Regarding the
remaining options, knowledge of respiratory anatomy will direct you to option 1.
Review anatomy of the respiratory system if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A nurse has instructed a client using an incentive spirometer to sustain the inhaled
breath for 3 seconds. When the client asks about the rationale for this action, the
nurse explains in simple terms that the primary benefit is to:
Options:
1. Dilate the major bronchi
2. Increase surfactant production
3. Enhance ciliary action in the tracheobronchial tree
4. Maintain inflation of the alveoli
Answer:
4.
Rationale:
Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli,
thereby promoting better gas exchange. Routine use of devices such as an incentive
spirometer can help prevent atelectasis and pneumonia in clients at risk for these
conditions. Therefore options 1, 2, and 3 are incorrect.
Strategy:
Recall anatomy and physiology of respiration to answer this question. Knowing that
the alveoli constitute the most distal portion of the respiratory tree will help you to
choose this option as the area to derive the benefit from maximum sustained
inhalation. If this question was difficult for you, review the respiratory process.
Reference:
Inc.
Question:
A nurse is assisting a respiratory therapist to position a client for postural drainage.
A nursing student asks the nurse how the respiratory therapist selects the position
used for the procedure. The nurse responds that a position is chosen that will use
gravity to help drain which of the following areas? Options:
1. Trachea
2. Main bronchi
3. Lobes
4. Alveoli
Answer:
3.
Rationale:
Postural drainage utilizes specific client positions that vary depending on the
affected lobe(s). The positions usually involve having the head lower than the
affected lung segment(s) to facilitate drainage of secretions. Postural drainage often
is done in conjunction with chest percussion for maximum effectiveness. The other
options are incorrect.
Strategy:
Use the process of elimination and focus on the subject, postural drainage.
Visualizing this procedure will direct you to option 3. Review this procedure if you
Reference:
Assessment and management of clinical problems (6th ed., pp. 673-674). St. Louis:
Mosby.
Inc.
Question:
A client s baseline vital signs are: temperature 98.8 F oral, pulse 74 beats/min,
respirations 18 breaths/min, and blood pressure (BP) 124/76 mm Hg. The client s
temperature suddenly spikes to 103 F. Which of the following respiratory rates
should the nurse anticipate in this client as part of the body s response to the
change in status?
Options:
1. 12 breaths/min
2. 16 breaths/min
3. 18 breaths/min
4. 22 breaths/min
Answer:
4.
Rationale:
Elevations in body temperature cause a corresponding increase in respiratory rate.
This occurs because the metabolic needs of the body increase with fever, requiring
more oxygen. The client who has a decrease in body temperature will experience a
decrease in respiratory rate.
Strategy:
To answer this question accurately, recall that with increased demand for oxygen,
the body will need an increased supply. With this principle in mind, you will easily be
able to eliminate each of the incorrect options, because they either go in the
opposite direction (options 1 and 2) or are unchanged (option 3). Review the
physiological responses to fever if you had difficulty with this question.
Reference:
Assessment and management of clinical problems (6th ed., pp. 211, 219). St. Louis:
Mosby.
Inc.
Question:
A client with postoperative incisional pain complains to the nurse about discomfort
with prescribed respiratory exercises. The client is willing to do the deep breathing
exercises but states that it hurts to cough. The nurse provides gentle
encouragement and appropriate pain management to the client, knowing that
coughing is needed to:
Options:
1. Expel mucus from the airways
2. Dilate the terminal bronchioles
3. Provide for increased oxygen tension in the alveoli
4. Exercise the muscles of respiration
Answer:
1.
Rationale:
Coughing is one of the protective reflexes. Its purpose is to move mucus that is in
the airways upward toward the mouth and nose. Coughing is needed in the
postoperative client to mobilize secretions and expel them from the airways. The
other options do not accurately describe this purpose.
Strategy:
Use principles of anatomy and physiology to answer this question. Recalling that the
cough reflex is a protective reflex that clears the airway will direct you to option 1.
Review the physiology related to the cough reflex if you had difficulty with this
question.
Reference:
Mosby.
Inc.
Question:
A nurse places a hospitalized client with active tuberculosis in a private, wellventilated isolation room. In addition, which critical action(s) should the nurse take
before entering the client s room? Options:
1. Wash the hands.
2. Wash the hands and place a high-efficiency particulate air (HEPA) respirator over
the nose and mouth.
3. The nurse needs no special precautions, but the client is instructed to cover his or
her mouth and nose when coughing or sneezing.
4. Wash the hands and wear a gown and gloves.
Answer:
2.
Rationale:
The nurse wears a HEPA respirator when caring for a client with active tuberculosis.
Hands are always thoroughly washed before and after caring for the client. Option 1
is an incomplete action. Option 3 is an incorrect statement. Option 4 is also
inaccurate and incomplete. Gowning is only indicated when there is a possibility of
contaminating clothing.
Strategy:
Use the process of elimination. Noting the client s diagnosis and recalling the need
for respiratory precautions will direct you to option 2. Review these respiratory
isolation precautions if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of
respiratory disease. The nurse anticipates that as the client s CO2 level rises, the
pH should:
Options:
1. Rise
2. Fall
3. Remain unchanged
4. Double
Answer:
2.
Rationale:
CO2 acts as an acid in the body. Therefore, in a respiratory disorder with a rise in
CO2, a corresponding fall in pH occurs. The other options are incorrect.

Strategy:
To answer this question accurately, you must understand the inverse relationship
between pH and the CO2 in the body in a respiratory condition. As CO2 rises, pH
falls, and as CO2 falls, pH rises. This concept forms the basis for key aspects of a
respiratory acid-base balance. Review these acid-base concepts if you had difficulty
with this question.
Reference:
Huether, S., & McCance, K. (2004). Understanding pathophysiology (3rd ed., pp.
118-120). St. Louis: Mosby.
Inc.
Question:
A nurse is evaluating the status of a client experiencing dyspnea. The nurse is
aware that which of the following factors will decrease the work of breathing for this
client?
Options:
1. Increased mucus production
2. Interstitial pulmonary edema
3. Increased airway resistance
4. Bronchodilation
Answer:
4.
Rationale:
Bronchodilation decreases the airway resistance and decreases the work of
breathing for the client. Clients with increased mucus production, edema, or
bronchospasm have increased airway resistance, which increases the work of
breathing.
Strategy:
Use the process of elimination and recall the various factors that enhance or inhibit
respiratory processes. The correct option is the only condition that allows air to
enter the lungs and perfuse the pulmonary capillaries. Review the factors that affect
airway resistance if you had difficulty with this question.
Reference:

Inc.
Question:
A nurse is instructing a client in diaphragmatic breathing. To reinforce the need for
this technique, the nurse teaches the client that in normal respiration, the
diaphragm:
Options:
1. Moves downward and out as it contracts
2. Moves up and inward as it contracts
3. Makes the thoracic cage smaller as it contracts
4. Aids in exhalation as it contracts
Answer:
1.
Rationale:
As the diaphragm contracts, it moves downward and out, becoming flatter and
expanding the thoracic cage. This process occurs during the inspiratory phase of the
respiratory cycle. Therefore, options 2, 3, and 4 are incorrect.
Strategy:
Focus on the subject, diaphragmatic breathing. Visualize the contraction of the
diaphragm and use the process of elimination to direct you to option 1. If this
question was difficult for you, review the process of respiration.
Reference:
Inc.
Question:
A nurse is reading the chest x-ray report for a client who has just been intubated.
The report states that the tip of the endotracheal tube lies 1 cm above the carina.
The nurse interprets that the tube is positioned above:
Options:
1. The point at which the larynx connects to the trachea
2. The area connecting the oropharynx to the laryngopharynx
3. The bifurcation of the right and left main bronchi
4. The first tracheal cartilaginous ring
Answer:
3.
Rationale:
The carina is a cartilaginous ridge that separates the openings of the two main
(right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube
will enter the right main bronchus due to the natural curvature of the airway. This is
hazardous because only the right lung will be ventilated. It is easily detected,
however, because breath sounds will be heard only over the right lung, and only the
right side of the chest will rise and fall with ventilation. Options 1, 2, and 4 are
incorrect.
Strategy:
Use the process of elimination. Recalling the anatomy of the respiratory system will
direct you to option 3. Review this anatomy if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is told to draw an arterial blood gas sample with the client on ambient
(room) air. The nurse documents in the record that the client was receiving how
much oxygen for this procedure? Options:
1. 16%
2. 21%
3. 30%
4. 40%
Answer:
2.
Rationale:
Ambient air is the same as room air, which contains 21% oxygen. It is not possible
to give a client 16% oxygen because it is less than room air. Options 3 and 4 contain
oxygen amounts that are commonly used to supplement clients having respiratory
difficulty.
Strategy:
Knowledge about the oxygen composition of room air or ambient air is needed to
answer this question. Remember that ambient air is the same as room air, which
contains 21% oxygen. This concept has important applications in the clinical setting,
so review this information if you had difficulty with this question.
Reference:
Inc.
Question:
A chest x-ray report for a client documents the presence of a left apical
pneumothorax. The nurse would assess the status of breath sounds in that area by
placing the stethoscope:
Options:
1. Posteriorly under the left scapula
2. Just under the left clavicle
3. Over the ffith intercostal space
4. Near the lateral twelfth rib
Answer:
2.
Rationale:
The nurse would place the stethoscope just under the left clavicle. The apex of the
lung is the rounded, uppermost part of the lung. All of the other options are
incorrect.
Strategy:
Focus on the client s diagnosis, and use knowledge of anatomical landmarks of the
respiratory system to answer this question. Recall that the apex of the lung is the
rounded, uppermost part of the lung. Review the basics of respiratory anatomy if
Reference:
St. Louis: Mosby. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed., pp.
643-645). St. Louis: Mosby. page 1 Elsevier items and derived items 2008 by
Question:
A client with a history of silicosis is admitted to the hospital with respiratory distress
and impending respiratory failure. The nurse plans to have which of the following
items readily available at the client s bedside?
Options:
1. Chest tube and drainage system
2. Intubation tray
3. Thoracentesis tray
4. Code cart
Answer:
2.
Rationale:
The client with impending respiratory failure may need intubation and mechanical
ventilation. The nurse ensures that an intubation tray is readily available. The other
items are not needed at the client s bedside.
Strategy:
Focus on the client s diagnosis. Use the ABCsairway, breathing, and circulation
to direct you to option 2. Review care of the client with impending respiratory failure
if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is planning to obtain blood for arterial blood gas (ABG) analysis from a client
with chronic obstructive pulmonary disease (COPD). The nurse plans time for which
activity after the arterial blood specimen is drawn?
Options:
1. Holding a warm compress over the puncture site for 5 minutes
2. Applying pressure to the puncture site by applying a 2 2 gauze for 5 minutes
3. Encouraging the client to open and close the hand rapidly for 2 minutes
4. Having the client keep the radial pulse puncture site in a dependent position for 5
minutes Answer:
2.
Rationale:
Applying pressure over the puncture site reduces the risk of hematoma formation
and damage to the artery. A cold compress would aid in limiting blood flow. Keeping
the extremity still and out of a dependent position will aid in the formation of a clot
at the puncture site.

Strategy:
Use the process of elimination. Focus on the subject, preventing bleeding. Options
1, 3, and 4 promote bleeding. Option 2 aids in the prevention of bleeding into the
surrounding tissues. Review nursing responsibilities after collection of ABG
specimens if you had difficulty with this question.
Reference:
Inc.
Question:
A client begins to experience drainage of small amounts of bright red blood from the
tracheostomy tube 24 hours after a supraglottic laryngectomy. The best nursing
action for this client would be to: Options:
1. Notify the surgeon.
2. Increase the frequency of suctioning.
3. Add moisture to the oxygen delivery system.
4. Document the character and amount of drainage.
Answer:
1.
Rationale:
Immediately after laryngectomy, a small amount of bleeding occurs from the
tracheostomy that resolves within the first few hours. Otherwise, bleeding that is
bright red may be a sign of impending rupture of a vessel. The bleeding in this
instance represents a potential threat to life, and the surgeon is notified to further
evaluate the client and suture or repair the source of the bleeding. The other
options do not address the urgency of the problem. Failure to notify the surgeon
places the client at risk.
Strategy:
Use the process of elimination. Note the strategic words bright red blood and 24
hours after . This phrasing indicates that a potential complication may be present.
Review complications after laryngectomy if you had difficulty with this question.
Reference:
Inc.
Question:
A client is to undergo pleural biopsy at the bedside. Knowing the potential
complications of the procedure, the nurse plans to have which of the following items
available at the bedside?
Options:
1. Chest tube and drainage system
2. Intubation tray
3. Portable chest x-ray machine
4. Morphine sulfate injection
Answer:
1.
Rationale:
Complications following pleural biopsy include hemothorax, pneumothorax, and
temporary pain from intercostal nerve injury. The nurse has a chest tube and
drainage system available at the bedside for use if hemothorax or pneumothorax
develops. An intubation tray is not indicated. The client may be premedicated
before the procedure, or a local anesthetic is used. A portable chest x-ray machine
would be called for to verify placement of a chest tube if one was inserted, but it is
unnecessary to have at the bedside before the procedure.
Strategy:
Note that the client is having a pleural biopsy. Recalling the complications of this
procedure will direct you to option 1. If this question was difficult for you, review the
content for this procedure and its complications.
Reference:
Inc.
Question:
A client is admitted to the hospital with a diagnosis of legionnaires disease. The
nurse is providing information regarding the disease and treatment expectations.
Which statement by the client indicates an understanding of the disease and
treatments?
Options:
1. I should avoid all contact with my family.
2. I should avoid large crowds for at least 3 weeks.
3. I cannot give legionnaires disease to other people.
4. I will have to take antibiotics until my symptoms disappear.
Answer:
3.
Rationale:
Legionnaires disease is spread through infected aeresolized water. The mode of
transmission is not person to person. Antibiotics must be given for the entire
duration of the prescription. Therefore, options 1, 2, and 4 are incorrect.
Strategy:
Use process of elimination. Recalling that legionnaires disease is not transmitted
person to person will assist in eliminating options 1 and 2. Next, remembering that
antibiotics must be given for the entire duration of the prescription will assist in
eliminating option 4. Review the treatment measures for this disorder if you had
Reference:
Mosby.
Inc.
Question:
The nurse is planning care for a 81-year-old unresponsive client admitted to the
hospital with a medical diagnosis of pneumonia. The nurse has identified a nursing
diagnosis of ineffective airway clearance related to retained secretions. Which of the
following is an appropriate intervention?
Options:
1. Initiate and maintain supplemental oxygen as prescribed.
2. Monitor oxygenation (the oxygen saturation [SaO2]) during activity.
3. Plan activities with rest periods to conserve oxygen needs.
4. Provide nasotracheal suctioning as needed to remove secretions.
Answer:
4.
Rationale:
Ineffective airway clearance reflects the client s inability to expectorate excretions.
The intervention specifically addressing retained secretions is option 4. Options 1
and 3 are interventions addressing an impaired gas exchange. Option 3 addresses

an activity intolerance diagnosis.
Strategy:
Use process of elimination and focus on the data in the question. Remember that
nursing interventions should address the etiology of the diagnostic statement. Also,
note the relationship between the words ineffective airway clearance related to
retained secretions in the question and option 4. Review interventions for ineffective
airway clearance if you had difficulty with this question.
Reference:
Mosby.
Inc.
Question:
A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of
24 breaths/min, bilateral crackles, and cyanosis and is coughing but is unable to
expectorate sputum. Which nursing diagnosis is the priority for this client?
Options:
1. Risk for decreased cardiac output secondary to cor pulmonale
2. Impaired gas exchange related to ventilation-perfusion mismatch
3. Ineffective breathing pattern related to increased work of breathing
4. Ineffective airway clearance related to inability to expectorate sputum
Answer:
4.
Rationale:
COPD is a term that represents the pathology and symptoms that occur with clients
experiencing both emphysema and chronic bronchitis. All of the diagnoses listed are
potentially appropriate for a client with COPD. For the nurse prioritizing this client s
problems, it is important to first maintain airway, breathing, and circulation. At
present, the client demonstrates problems with ventilation because of ineffective
coughing, so option 4 would be the priority problem. The bilateral crackles would
suggest fluid or sputum in the alveoli or airways; however, the client is unable to
expectorate this sputum. The client s respiratory rate is only slightly elevated, so
ineffective breathing pattern is not as important as airway. The client is cyanotic,
but this probably is due to the ineffective clearance of the sputum, causing poor gas
exchange. The data in the question do not support decreased cardiac output as
being most important at this time. Level of Cognitive Ability - Analysis

Strategy:
Focus on the data in the question and note that the client is unable to expectorate
sputum. This will direct you to option 4. Review the defining characteristics for
ineffective airway clearance if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is performing a respiratory assessment on a client with a left lower lobe
lung mass. Chest auscultation over the posterior left lower lobe reveals these breath
sounds. (Click on sound icon.) The nurse would interpret these sounds to be which
of the following?
Options:
2. Vesicular breath sounds
3. Bronchial breath sounds
4. Bronchovesicular breath sounds
Answer:
3.
Rationale:
The sounds that the nurse hears are bronchial breath sounds. Bronchial breath
sounds are loud, high- pitched sounds that resemble air blowing through a hollow
pipe. The expiration phase is louder and longer than the inspiration phase, and a
distinct pause can be heard between the inspiration and expiration phases.
Bronchial breath sounds normally are heard only over the trachea and immediately
above the manubrium. Bronchial breath sounds are abnormal anywhere over the
posterior or lateral chest. When heard in these areas, they indicate abnormal sound
transmission because of consolidation of lung tissue, as in a lung mass, atelectasis,
or pneumonia. A pleural friction rub is a superficial, low- pitched, coarse rubbing or
grating sound that sounds like two rough surfaces rubbing together and is heard in
the client with pleurisy. Vesicular breath sounds normally are heard over the lesser
bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and
low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath
sounds normally are heard over the first and second intercostal spaces at the
sternal border anteriorly and at T4 medial to the scapula posteriorly. These sounds
are a mixture of bronchial and vesicular breath sounds and are of moderate pitch
with a medium intensity.
Strategy:
Listen to the sound and note that it is a loud, high-pitched sound that resembles air
blowing through a hollow pipe. Also focus on the client s diagnosis and remember
that auscultation over areas of consolidation of lung tissue will reveal bronchial
breath sounds. Review the characteristics of bronchial breath sounds and the
expected findings in the client with a lung mass if you had difficulty with this
question.
Reference:
Wilson, S., & Giddens, J. (2005). Health assessment for nursing practice (3rd ed., pp.
347-349; CD: Lung Sounds). St. Louis: Mosby.
Inc.
Question:
A nurse is performing a respiratory assessment on a client with a left lower lobe
lung mass. Chest auscultation over the posterior left lower lobe reveals these breath
sounds. (Click on sound icon.) The nurse would interpret these sounds to be which
of the following?
Options:
2. Vesicular breath sounds
Answer:
3.
Rationale:
The sounds that the nurse hears are bronchial breath sounds. Bronchial breath
sounds are loud, high- pitched sounds that resemble air blowing through a hollow
pipe. The expiration phase is louder and longer than the inspiration phase, and a
distinct pause can be heard between the inspiration and expiration phases.
Bronchial breath sounds normally are heard only over the trachea and immediately
above the manubrium. Bronchial breath sounds are abnormal anywhere over the
posterior or lateral chest. When heard in these areas, they indicate abnormal sound
transmission because of consolidation of lung tissue, as in a lung mass, atelectasis,
or pneumonia. A pleural friction rub is a superficial, low- pitched, coarse rubbing or
grating sound that sounds like two rough surfaces rubbing together and is heard in
the client with pleurisy. Vesicular breath sounds normally are heard over the lesser
bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and
low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath
sounds normally are heard over the first and second intercostal spaces at the
sternal border anteriorly and at T4 medial to the scapula posteriorly. These sounds
are a mixture of bronchial and vesicular breath sounds and are of moderate pitch
with a medium intensity.
Strategy:
Listen to the sound and note that it is a loud, high-pitched sound that resembles air
blowing through a hollow pipe. Also focus on the client s diagnosis and remember
that auscultation over areas of consolidation of lung tissue will reveal bronchial
breath sounds. Review the characteristics of bronchial breath sounds and the
expected findings in the client with a lung mass if you had difficulty with this
question.
Reference:
347-349; CD: Lung Sounds). St. Louis: Mosby.
Inc.
Question:
An emergency department nurse is performing a respiratory assessment on a client
complaining of painful breathing. On palpation the nurse notes a coarse grating
sensation during inspiration, and on auscultation the nurse hears this breath sound.
(Click on sound icon.) The nurse interprets that these findings are characteristic of
which of the following?
Options:
1. Asthma
2. Pleurisy
3. Emphysema
4. Pulmonary edema
Answer:
2.
Rationale:
The sound that the nurse hears is a pleural friction rub. Pleural friction rubs are the
result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural
infarction. It is a superficial, low- pitched, coarse rubbing or grating sound that

sounds like two rough surfaces are rubbing together. A pleural friction rub is heard
throughout inspiration and expiration and is loudest over the lower anterolateral
surface. It is not cleared by a cough. Disorders that cause airflow obstruction such
as emphysema or asthma would produce high-pitched or low-pitched wheezes
(musical sounds similar to a squeak). Crackles occur with sudden opening of small
airways that contain fluid, usually are heard during inspiration, and do not clear with
a cough. Crackles resemble the sound of a lock of hair being rubbed between the
thumb and forefinger and are heard in conditions such as pulmonary edema. Level
of Cognitive Ability - Analysis
Strategy:
Listen to the sound and note that its characteristics indicate a coarse rubbing or
grating sound that sounds like two rough surfaces are rubbing together. Remember
that when breath sounds are heard as two surfaces rub bing together, they are
indicative of a pleural friction rub . Review the characteristics of a pleural friction
rub if you had difficulty with this question.
Reference:
343, 349; CD: Lung Sounds). St. Louis: Mosby.
Inc.
Some material Question:
A nurse is auscultating breath sounds in a hospitalized client with emphysema and
hears these sounds. (Click on sound icon.) The nurse documents this finding as
which of the following?
Options:
1. Crackles
2. High-pitched wheezes
Answer:
2.
Rationale:
The sounds that the nurse hears are high-pitched wheezes. These are musical
sounds that predominate in expiration but may occur in both expiration and
inspiration. They occur in the small airways and are heard in narrowed airway
diseases such as asthma or emphysema. Crackles resemble the sound of a lock of
hair being rubbed between the thumb and forefinger. Crackles occur with sudden
opening of small airways that contain fluid, usually are heard during inspiration, and
do not clear with a cough. Crackles are heard in conditions such as congestive heart
failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds
that resemble air blowing through a hollow pipe. Bronchial breath sounds normally
are heard only over the trachea and immediately above the manubrium. Bronchial
breath sounds are abnormal anywhere over the posterior or lateral chest. When
they are heard in these areas, they indicate abnormal sound transmission because
of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia.
Bronchovesicular breath sounds normally are heard over the first and second
intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula
posteriorly (over major bronchi). These sounds are a mixture of bronchial and
vesicular breath sounds and are of moderate pitch with a medium intensity.
Strategy:
Listen to the sound and note that it is a musical sound that predominates in
expiration but may occur in both expiration and inspiration. This will assist in
answering the question. Also focus on the client s diagnosis and recall that wheezes
are heard in narrowed airway disease. Review the characteristics of wheezes if you
Reference:
347, 349; CD: Lung Sounds). St. Louis: Mosby.
Inc.
Question:
An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse
interprets that which of the following client manifestations is unrelated to this
problem?
Options:
1. Purulent nasal discharge
2. Chronic cough
3. Headache more pronounced in the evening
4. Anosmia
Answer:
3.
Rationale:
Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic
cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and
headache that is worse on arising after sleep. Level of Cognitive Ability - Analysis
Strategy:
Use the process of elimination. Noting the strategic word unrelated and knowledge
of the signs and symptoms of sinusitis will direct you to option 3. Review these signs
and symptoms if you had difficulty with this question.
Reference:
Inc.
Question:
A clinic nurse notes that large numbers of clients whose chief complaint is the
presence of flu-like symptoms are being seen in the clinic. Which of the following
recommendations by the nurse would be least helpful for these clients?
Options:
1. Increase intake of liquids.
2. Take antipyretics for fever.
3. Get a flu shot immediately.
4. Get plenty of rest.
Answer:
3.
Rationale:
Immunization against influenza is a prophylactic measure and is not used to treat
flu symptoms. Treatment for the flu includes getting rest, drinking fluids, and taking
in nutritious foods and beverages. Medications such as antipyretics and analgesics
also may be used for symptom management. Level of Cognitive Ability Application
Strategy:
Use the process of elimination, noting the strategic words least helpful . Recalling
that a flu shot is a prophylactic measure will assist in directing you to the correct
option. Review care measures for the client with flu-like symptoms if you had
Reference:

Inc.
Question:
A client seeks treatment in an ambulatory clinic for a complaint of hoarseness that
has lasted for 6 weeks. On the basis of this symptom, the nurse interprets that the
client is at risk for a diagnosis of: Options:
1. Laryngeal cancer
2. Acute laryngitis
3. Bronchogenic cancer
4. Thyroid cancer
Answer:
1.
Rationale:
Hoarseness is a common early sign of laryngeal cancer, but not of bronchogenic or
thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute
problem, such as laryngitis. Level of Cognitive Ability - Analysis
Strategy:
Use the process of elimination. Begin to answer this question by eliminating option
2, because an acute problem generally would not last for 6 weeks. Regarding the
remaining options, recalling that the vocal cords are in the larynx makes option 1
preferable to any of the others. Review the signs of laryngeal cancer if you had
Reference:
Inc.
Question:
A nurse is auscultating the chest of a client with new-onset pleurisy. The client does
not have a pleural friction rub, which was auscultated the previous day. The nurse
interprets that this change is most likely to be due to:
Options:
1. Decreased inflammatory reaction at the site
2. The deep breaths that the client is taking
3. Accumulation of pleural fluid in the inflamed area
4. Effectiveness of medication therapy

Answer:
3.
Rationale:
Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid
accumulates. Once fluid accumulates in the inflamed area, friction between the
visceral and parietal lung surfaces decreases, and the pleural friction rub
disappears. Options 1, 2, and 4 are incorrect interpretations. Level of Cognitive
Ability - Analysis
Strategy:
Use the process of elimination. Eliminate option 2 first, which would intensify the
pain. Options 1 and 4 are comparative or alike, and because the question states
that the problem is of new onset, these should be eliminated next. Recall that fluid
accumulation in the area provides a buffer between the lung and chest wall
surfaces, which eliminates the friction rub. Review assessment findings in the client
with pleurisy if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse witnesses an accident whereby a pedestrian is hit by an automobile. The
nurse stops at the scene and assesses the victim. The nurse notes that the victim is
responsive and has suffered trauma to the thorax resulting in a flail chest involving
at least three ribs. The nurse does which of the following to assist the victim s
respiratory status until help arrives?
Options:
1. Assists the victim to sit up
2. Turns the victim onto the side with the flail chest
3. Removes the victim s shirt
4. Applies firm but gentle pressure with the hands to the flail segment
Answer:
4.
Rationale:
If significant flail chest is present, the nurse applies firm yet gentle pressure to the
flail segments of the ribs to stabilize the chest wall, which will ultimately help the
victim s respiratory status. The nurse does not move an injured person for fear of
worsening an undetected spinal injury. Removing the victim s shirt is of no value in
this situation and could in fact result in chilling the victim, which is
counterproductive. Injured persons should be kept warm until help arrives at the
scene.
Strategy:
Use knowledge of the principles of respiration and emergency nursing to answer
this question. Eliminate options 1 and 2 because the victim should not be moved.
Regarding the remaining options, recalling that the victim should be kept warm will
direct you to option 4. Review emergency care of the victim with flail chest if you
Reference:
Inc.
Question:
A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis.
The nurse carries out which of the following prescribed measures as the most
effective means to treat the problem? Options:
1. Administers prescribed antibiotics
2. Administers antipyretics as needed (on PRN basis)
3. Has the client breathe into a paper bag
4. Requests an order for a partial rebreather oxygen mask
Answer:
1.
Rationale:
The most effective way to treat an acid-base disorder is to treat the underlying
cause of the disorder. In this case, the problem is sepsis, which is most effectively
treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis
but do nothing to treat the acid-base balance. The paper bag and partial rebreather
mask will assist the client to rebreathe exhaled carbon dioxide, but again, these do
not treat the primary cause of the imbalance.

Strategy:
Note the strategic words sepsis and most effective . Recalling that the most
effective treatment of acid- base imbalances involves treatment of the primary
cause will direct you to option 1. Also recall that sepsis is a systemic infection and is
treated with antibiotics. Review the treatment for respiratory alkalosis and sepsis if
Reference:
Inc.
Question:
A nurse is performing a cardiovascular assessment on a client. Which of the
following parameters would the nurse assess to gain the best information about the
client s left-sided heart function?
Options:
1. Breath sounds
2. Peripheral edema
3. Jugular vein distention
4. Hepatojugular reflux
Answer:
1.
Rationale:
The client with heart failure may present with different symptoms according to
whether the right or the left side of the heart is failing. Peripheral edema, jugular
vein distention, and hepatojugular reflux all are indicators of impaired right-sided
heart function. Breath sounds are an accurate indicator of left-sided heart function.
Strategy:
Focus on the subject, left-sided heart failure. Note the association of l eft and l ungs.
Left-sided heart failure leads to respiratory signs and symptoms. Review the signs
and symptoms of right- and left-sided heart failure if you had difficulty with this
question.
Reference:
Inc.
Question:
A nurse is caring for a group of clients on the clinical nursing unit. The nurse
interprets that which of these clients is at most risk for the development of
pulmonary embolism?
Options:
1. A 65-year-old man out of bed 1 day after prostate resection
2. A 73-year-old woman who has just had pinning of a hip fracture
3. A 25-year-old woman with diabetic ketoacidosis
4. A 38-year-old man with pulmonary contusion sustained in an automobile crash
Answer:
2.
Rationale:
Clients frequently at risk for pulmonary embolism include clients who are
immobilized. This is especially true in the immobilized postoperative client. Other
causes include those with conditions that are characterized by hypercoagulability,
endothelial disease, or advancing age.
Strategy:
The options can best be compared by evaluating the degree of immobility that each
client has, and also considering the age of the client, which is provided in each
option. The clients in options 1 and 3 have the least long-term anticipated
immobility and therefore should be eliminated first. Regarding the remaining
options, the younger client with the pulmonary contusion would be expected to be
less immobile than the older woman with hip fracture. Review the causes of
pulmonary embolism if you had difficulty with this question.
Reference:
for collaborative care (5th ed., pp. 387-388, 650). Philadelphia: W.B. Saunders.
Inc.
Question:
A nurse monitors the respiratory status of the client being treated for acute
exacerbation of chronic obstructive pulmonary disease (COPD). Which of the
following assessment findings would indicate a deterioration in ventilation?
Options:
1. Cyanosis
2. Rapid, shallow respirations
3. Hyperinflated chest
4. Coarse crackles auscultated bilaterally
Answer:
2.
Rationale:
An increase in the rate of respirations and a decrease in the depth of respirations
together indicate a deterioration in ventilation. Cyanosis is not a good indicator of
oxygenation in the client with COPD. Cyanosis may be present with some but not all
clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory
muscles of the upper chest and neck are common features of chronic COPD. During
an exacerbation, coarse crackles are expected to be heard bilaterally throughout
the lungs but do not indicate deterioration in ventilation.
Strategy:
Note the strategic words deterioration in ventilation . Recalling the normal clinical
signs seen in COPD and the signs of exacerbation, eliminate options 3 and 4.
Because cyanosis is not a good indicator of oxygenation in the client with COPD,
eliminate option 1. Review the clinical manifestations associated with COPD and a
deterioration in ventilation, if you had difficulty with this question.
Reference:
Inc.
Question:
A nurse is providing immediate postprocedure care to a client who had a
thoracentesis to relieve a tension pneumothorax that resulted from rib fractures.
The goal is that the client will exhibit normal respiratory functioning, and the nurse
provides instructions to assist the client toward this goal. Which statement by the
client indicates that further instruction is needed?
Options:
1. I will let you know at once if I have trouble breathing.
2. I will lie on the affected side for an hour.
3. I can expect a chest x-ray exam to be done shortly.
4. I will notify you if I feel a crackling sensation in my chest.

Answer:
2.
Rationale:
After the procedure, the client usually is turned onto the unaffected side for 1 hour
to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or
diminished breath sounds, which may indicate pneumothorax, should be reported to
the physician. A chest x-ray exam may be performed to evaluate the degree of lung
re-expansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow
this procedure, because air in the pleural cavity leaks into subcutaneous tissues.
The involved tissues feel like lumpy paper and crackle when palpated (crepitus).
Usually subcutaneous emphysema causes no problems unless it is increasing and
constricting vital organs, such as the trachea.
Strategy:
Use the process of elimination, noting the strategic words further instruction is
needed . Focus on the subject, postprocedure care after thoracentesis. Note that
option 2 states the affected side for an hour . Recall that facilitating lung expansion
is important. Noting the words affected side in option 2 will direct you to this option.
Review postprocedure care for a client who has had a thoracentesis if you had
Reference:
Inc.

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EXCLUSIVELY FOR PBL-B6.

4. Increase the suction pressure so that the bubbling becomes vigorous.

Integrated Process - Nursing ProcessImplementation

Content Area - Adult HealthRespiratory

Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking

Client Needs - Physiological Integrity

Level of Cognitive Ability - Analysis

2. Low arterial PaO2

Level of Cognitive Ability - Application

4. Acute respiratory distress syndrome

history of a respiratory disorder with hypercapnia, increases of 5 mm Hg or more

4. Uncertain and unexpected

imprint of Elsevier Inc.

3. I can return to work if a sputum culture comes back negative.

Content Area - Adult HealthRespiratory

Integrated Process - Nursing ProcessPlanning

Content Area - Adult HealthRespiratory

1. I need to be sure that no one smokes in my home.

Client Needs - Physiological Integrity

following coexisting problems?

A helpful concept to remember in answering this question is that fatigue due to

for collaborative care (5th ed., p. 641). Philadelphia: W.B. Saunders.

Client Needs - Physiological Integrity

nurse instructs the client to:

4. Manually ventilate the client with a resuscitation device.

Level of Cognitive Ability - Analysis

is occlusive. The use of Telfa, Neosporin ointment, hydrocolloid dressing, and

Content Area - Adult HealthRespiratory

3. The system needs changing.

Level of Cognitive Ability - Application

positive outcomes (7th ed., pp. 1861-1862). Philadelphia: W.B. Saunders.

for collaborative care (5th ed., p. 618). Philadelphia: W.B. Saunders.

1. A disconnection of the ventilator tubing

accumulation of secretions, condensation of water in the ventilator tubing,

Integrated Process - Nursing ProcessAnalysis

for collaborative care (5th ed., p. 657). Philadelphia: W.B. Saunders.

1. The point at which the larynx connects to the trachea

Level of Cognitive Ability - Application

4. Serous with sputum

United States from a foreign country. The nurse interprets that:

client s respiratory status would be monitored closely until a normal respiratory

Integrated Process - Nursing ProcessAnalysis

positive outcomes (7th ed., pp. 493-494). Philadelphia: W.B. Saunders.

Level of Cognitive Ability - Application

and 3 are interventions addressing an impaired gas exchange. Option 3 addresses

Client Needs - Physiological Integrity

infarction. It is a superficial, low- pitched, coarse rubbing or grating sound that

Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking

4. Effectiveness of medication therapy

Content Area - Adult HealthRespiratory

4. I will notify you if I feel a crackling sensation in my chest.

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