. 2.

Question
A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse
monitors the client for which side effect of this medication?
 A. Constipation
 B. Diarrhea
 C. Bradycardia
 D. Tachycardia

Correct Answer: D. Tachycardia

Side effects that can occur from a beta 2 agonist include tremors, nausea, nervousness,
palpitations, tachycardia, peripheral vasodilation, and dryness of the mouth or throat. Due to
the vasodilatory effect of peripheral vasculature and subsequent decrease in cardiac venous
return, compensatory mechanisms manifest as tachycardia are relatively common, especially
within the first weeks of usage.
. 3. Question
A nurse teaches a client about the use of a respiratory inhaler. Which action by the client
indicated a need for further teaching?
 A. Removes the cap and shakes the inhaler well before use.
 B. Press the canister down with your finger as he breathes in.
 C. Inhales the mist and quickly exhales.
 D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed.

Correct Answer: C. Inhales the mist and quickly exhales.

Take the inhaler out of the mouth. If the client can, he should hold his breath as he slowly
counts to 10. This lets the medicine reach deep into the lungs. The client should be instructed
to hold his or her breath at least 10 to 15 seconds before exhaling the mist.
. 4. Question
A female client is scheduled to have a chest radiograph. Which of the following questions is
of most importance to the nurse assessing this client?
 A. “Is there any possibility that you could be pregnant?”
 B. “Are you wearing any metal chains or jewelry?”
 C. “Can you hold your breath easily?”
 D. “Are you able to hold your arms above your head?”

Correct Answer: A. “Is there any possibility that you could be pregnant?”
The most important item to ask about is the client’s pregnancy status because pregnant
women should not be exposed to radiation. The risk of side effects of an X-ray while the
client is pregnant is extremely minimal, but it is always important to protect the developing
fetus from harm.
. 5. 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?
 A. Encouraging additional fluids for the next 24 hours
 B. Ensuring the return of the gag reflex before offering foods or fluids
 C. Administering atropine intravenously
 D. Administering small doses of midazolam (Versed).
Correct Answer: B. Ensuring the return of the gag reflex before offering foods or fluids
After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns
because the preoperative sedation and the local anesthesia impair swallowing and the
protective laryngeal reflexes for a number of hours. Although bronchoscopy can be done
without sedation, most procedures are done under moderate conscious sedation with the use
of various sedatives based on the clinician’s preference (e.g., benzodiazepines, opioids,
dexmedetomidine).
. 6. Question
A client has an order to have radial ABG drawn. Before drawing the sample, a nurse occludes
the:
 A. Brachial and radial arteries, and then releases them and observes the circulation of the
hand.
 B. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the
process with the other artery.
 C. Radial artery and observes for color changes in the affected hand.
 D. Ulnar artery and observes for color changes in the affected hand.
Correct Answer: B. Radial and ulnar arteries, releases one, evaluates the color of the
hand, and repeats the process with the other artery.
Before drawing an ABG, 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. This 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.
7. 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?
 A. Chronic obstructive bronchitis
 B. Emphysema
 C. Bronchial asthma
 D. Bronchial asthma and bronchitis

Correct Answer: B. Emphysema

The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm.
These lead to increased anteroposterior diameter, which is referred to as “barrel chest.” The
client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.
. 9. Question
Which of the following would be an expected outcome for a client recovering from an upper
respiratory tract infection? The client will:
 A. Maintain a fluid intake of 800 ml every 24 hours.
 B. Experience chills only once a day.
 C. Cough productively without chest discomfort.
 D. Experience less nasal obstruction and discharge.
Correct Answer: D. Experience less nasal obstruction and discharge.
A client recovering from an URI should report decreasing or no nasal discharge and
obstruction. Decongestants and combination antihistamine/decongestant medications can
limit cough, congestion, and other symptoms in adults. Avoid cough preparations in children.
H1-receptor antagonists may offer a modest reduction of rhinorrhea and sneezing during the
first 2 days of a cold in adults.
. 10. Question
Which of the following individuals would the nurse consider to have the highest priority for
receiving an influenza vaccination?
 A. A 60-year-old man with a hiatal hernia.
 B. A 36-year-old woman with 3 children.
 C. A 50-year-old woman caring for a spouse with cancer.
 D. A 60-year-old woman with osteoarthritis.

Correct Answer: C. A 50-year-old woman caring for a spouse with cancer.

Individuals who are household members or home care providers for high-risk individuals are
high-priority targeted groups for immunization against influenza to prevent transmission to
those who have a decreased capacity to deal with the disease. The wife who is caring for a
husband with cancer has the highest priority of the clients described.
. 11. Question
A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms.
Which of the following instructions would be appropriate for the nurse to give the client?
 A. “Use your nasal decongestant spray regularly to help clear your nasal passages.”
 B. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”
 C. “It is important to increase your activity. A daily brisk walk will help promote
drainage.”
 D. “Keep a diary when your symptoms occur. This can help you identify what
precipitates your attacks.”

Correct Answer: D. “Keep a diary when your symptoms occur. This can help you
identify what precipitates your attacks.”
It is important for clients with allergic rhinitis to determine the precipitating factors so that
they can be avoided. Keeping a diary can help identify these triggers. Patients often
underestimate the severity of this condition and fail to seek medical therapy. It is important to
adequately control AR, especially due to the link between AR and asthma, with poor control
of rhinitis predicting poor control of asthma.
. 14. Question
Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following
is a possible side effect of this drug?
 A. Constipation
 B. Bradycardia
 C. Diplopia
 D. Restlessness

Correct Answer: D. Restlessness

Side effects of pseudoephedrine are experienced primarily in the cardiovascular system and
through sympathetic effects on the CNS. The most common CNS effects include restlessness,
dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular side effects
include tachycardia, hypertension, palpitations, and arrhythmias.
. 15. Question
A client with COPD reports steady weight loss and being “too tired from just breathing to
eat.” Which of the following nursing diagnoses would be most appropriate when planning
nutritional interventions for this client?
 A. Altered nutrition: Less than body requirements related to fatigue.
 B. Activity intolerance related to dyspnea.
 C. Weight loss related to COPD.
 D. Ineffective breathing pattern related to alveolar hypoventilation.

Correct Answer: A. Altered nutrition: Less than body requirements related to fatigue.
The client’s problem is altered nutrition—specifically, less than required. The cause, as stated
by the client, is the fatigue associated with the disease process. Instruct the patient to
frequently eat high caloric foods in smaller portions. COPD patients expend an extraordinary
amount of energy simply on breathing and require high caloric meals to maintain body
weight and muscle mass.
. 16. Question
When developing a discharge plan to manage the care of a client with COPD, the nurse
should anticipate that the client will do which of the following?
 A. Develop infections easily.
 B. Maintain current status.
 C. Require less supplemental oxygen.
 D. Show permanent improvement.

Correct Answer: A. Develop infections easily.

A client with COPD is at high risk for development of respiratory infections. In emphysema,
an irritant (e.g., smoking) causes an inflammatory response. Neutrophils and macrophages
are recruited and release multiple inflammatory mediators. Oxidants and excess proteases
leading to the destruction of the air sacs. The protease-mediated destruction of elastin leads to
a loss of elastic recoil and results in airway collapse during exhalation.
. 17. Question
Which of the following outcomes would be appropriate for a client with COPD who has been
discharged to home? The client:
 A. Promises to do pursed lip breathing at home.
 B. States actions to reduce pain.
 C. States that he will use oxygen via a nasal cannula at 5 L/minute.
 D. Agrees to call the physician if dyspnea on exertion increases.

Correct Answer: D. Agrees to call the physician if dyspnea on exertion increases.

Increasing dyspnea on exertion indicates that the client may be experiencing complications of
COPD, and therefore the physician should be notified. There are things that everyone with
COPD should do to manage their disease; quitting smoking (if they smoke) is the most
important. In addition, there are other non-medication treatments that can help relieve
symptoms and improve quality of life.
. 18. Question
Which of the following physical assessment findings would the nurse expect to find in a
client with advanced COPD?
 A. Increased anteroposterior chest diameter.
 B. Underdeveloped neck muscles.
 C. Collapsed neck veins.
 D. Increased chest excursions with respiration.

Correct Answer: A. Increased anteroposterior chest diameter.

Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped
in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the
typical barrel-chested appearance. In addition, coarse crackles beginning with inspiration may
be heard.
. 19. Question
Which of the following is the primary reason to teach pursed-lip breathing to clients with
emphysema?
 A. To promote oxygen intake.
 B. To strengthen the diaphragm.
 C. To strengthen the intercostal muscles.
 D. To promote carbon dioxide elimination.

Correct Answer: D. To promote carbon dioxide elimination.

Pursed lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby
promoting carbon dioxide elimination. By prolonged exhalation and helping the client relax,
pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-
lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen
intercostal muscles.
. 20. Question
Which of the following is a priority goal for the client with COPD?
 A. Maintaining functional ability.
 B. Minimizing chest pain.
 C. Increasing carbon dioxide levels in the blood.
 D. Treating infectious agents.

Correct Answer: A. Maintaining functional ability

A priority goal for the client with COPD is to manage the s/s of the disease process so as to
maintain the client’s functional ability. Evaluate the level of activity tolerance. Provide a
calm, quiet environment. Limit a patient’s activity or encourage bed or chair rest during the
acute phase. Have patient resume activity gradually and increase as individually tolerated.
. 21. Question
A client’s arterial blood gas levels are as follows: pH 7.31; PaO2 80 mm Hg, PaCO2 65 mm
Hg; HCO3- 36 mEq/L. Which of the following signs or symptoms would the nurse expect?
 A. Cyanosis
 B. Flushed skin
 C. Irritability
 D. Anxiety

Correct Answer: B. Flushed skin

The high PaCO2 level causes flushing due to vasodilation. The client also becomes drowsy
and lethargic because carbon dioxide has a depressant effect on the CNS. On the contrary,
chronic respiratory acidosis may be caused by COPD where there is a decreased
responsiveness of the reflexes to states of hypoxia and hypercapnia.
.
. 23. Question
The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of
the following s/s would be included in the teaching plan?
 A. Clubbing of nail beds
 B. Hypertension
 C. Peripheral edema
 D. Increased appetite

Correct Answer: C. Peripheral edema

Right-sided heart failure is a complication of COPD that occurs because of pulmonary
hypertension. Signs and symptoms of right-sided heart failure include peripheral edema,
jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume.
Right heart failure is most commonly a result of left ventricular failure via volume and
pressure overload. Clinically, patients will present with signs and symptoms of chest
discomfort, breathlessness, palpitations, and body swelling.

. 24. Question
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of
COPD secondary to an upper respiratory tract infection. Which of the following findings
would be expected?
 A. Normal breath sounds
 B. Prolonged inspiration
 C. Normal chest movement
 D. Coarse crackles and rhonchi

Correct Answer: D. Coarse crackles and rhonchi

Exacerbations of COPD are frequently caused by respiratory infections. Coarse crackles and
rhonchi would be auscultated as air moves through airways obstructed with secretions.
Crackles are usually due to airway secretions within a large airway and disappear on
coughing. These crackles are scanty, gravity-independent, usually audible at the mouth, and
strongly associated with severe airway obstruction.
. 25. Question
Which of the following ABG abnormalities should the nurse anticipate in a client with
advanced COPD?
 A. Increased PaCO2
 B. Increased PaO2
 C. Increased pH
 D. Increased oxygen saturation

Correct Answer: A. Increased PaCO2

As COPD progresses, the client typically develops increased PaCO2 levels and decreased
PaO2 levels. This results in decreased pH and decreased oxygen saturation. These changes
are the result of air trapping and hypoventilation. Arterial blood gas (ABG) analysis provides
the best clues as to acuteness and severity of disease exacerbation.
. 26. Question
Which of the following diets would be most appropriate for a client with COPD?
 A. Low fat, low cholesterol
 B. Bland, soft diet
 C. Low-Sodium diet
 D. High calorie, high-protein diet

Correct Answer: D. High-calorie, high-protein diet

The client should eat high-calorie, high-protein meals to maintain nutritional status and
prevent weight loss that results from the increased work of breathing. The client should be
encouraged to eat small, frequent meals. Eat 20 to 30 grams of fiber each day, from items
such as bread, pasta, nuts, seeds, fruits and vegetables. Eat a good source of protein at least
twice a day to help maintain strong respiratory muscles. Good choices include milk, eggs,
cheese, meat, fish, poultry, nuts and dried beans or peas.
. 29. Question
The nurse would anticipate which of the following ABG results in a client experiencing a
prolonged, severe asthma attack?
 A. Decreased PaCO2, increased PaO2, and decreased pH.
 B. Increased PaCO2, decreased PaO2, and decreased pH.
 C. Increased PaCO2, increased PaO2, and increased pH.
 D. Decreased PaCO2, decreased PaO2, and increased pH.

Correct Answer: B. Increased PaCO2, decreased PaO2, and decreased pH.

As the severe asthma attack worsens, the client becomes fatigued and alveolar hypotension
develops. This leads to carbon dioxide retention and hypoxemia. The client develops
respiratory acidosis. Therefore, the PaCO2 level increases, the PaO2 level decreases, and the
pH decreases, indicating acidosis.

. 30. Question
A client with acute asthma is prescribed short-term corticosteroid therapy. What is the
rationale for the use of steroids in clients with asthma?
 A. Corticosteroids promote bronchodilation.
 B. Corticosteroids act as an expectorant.
 C. Corticosteroids have an anti-inflammatory effect.
 D. Corticosteroids prevent development of respiratory infections.

Correct Answer: C. Corticosteroids have an anti-inflammatory effect.

Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial
airways and decrease mucus secretion. At a physiologic level, steroids reduce airway
inflammation and mucus production and potentiate beta-agonist activity in smooth muscles
and reduce beta-agonists tachyphylaxis in patients with severe asthma. Corticosteroids do not
have a bronchodilator effect, act as expectorants, or prevent respiratory infections.
. 34. Question
Which of the following health promotion activities should the nurse include in the discharge
teaching plan for a client with asthma?
 A. Incorporate physical exercise as tolerated into the treatment plan.
 B. Monitor peak flow numbers after meals and at bedtime.
 C. Eliminate stressors in the work and home environment.
 D. Use sedatives to ensure uninterrupted sleep at night.

Correct Answer: A. Incorporate physical exercise as tolerated into the treatment plan.
Physical exercise is beneficial and should be incorporated as tolerated into the client’s
schedule. Peak flow numbers should be monitored daily, usually in the morning (before
taking medication). Encourage breathing exercises and controlled breathing and relaxation.
Prevents attack before it begins and increases ventilation.
. 35. Question
The client with asthma should be taught which of the following is one of the most common
precipitating factors of an acute asthma attack?
 A. Occupational exposure to toxins.
 B. Viral respiratory infections.
 C. Exposure to cigarette smoke.
 D. Exercising in cold temperatures.

Correct Answer: B. Viral respiratory infections.

The most common precipitator of asthma attacks is viral respiratory infection. Clients with
asthma should avoid people who have the flu or a cold and should get yearly flu vaccinations.
Asthma is a condition of acute, fully reversible airway inflammation, often following
exposure to an environmental trigger. The pathological process begins with the inhalation of
an irritant (e.g., cold air) or an allergen (e.g., pollen), which then, due to bronchial
hypersensitivity, leads to airway inflammation and an increase in mucus production. This
leads to a significant increase in airway resistance, which is most pronounced on expiration.
. 37. Question
Basilar crackles are present in a client’s lungs on auscultation. The nurse knows that these are
discrete, non continuous sounds that are:
 A. Caused by the sudden opening of alveoli.
 B. Usually more prominent during expiration.
 C. Produced by airflow across passages narrowed by secretions.
 D. Found primarily in the pleura.

Correct Answer: A. Caused by the sudden opening of alveoli

Basilar crackles are usually heard during inspiration and are caused by sudden opening of the
alveoli. Basilar crackles are a bubbling or crackling sound originating from the base of the
lungs. They may occur when the lungs inflate or deflate. They’re usually brief, and may be
described as sounding wet or dry. Excess fluid in the airways causes these sounds.
. 38. Question
A cyanotic client with an unknown diagnosis is admitted to the E.R. In relation to oxygen, the
first nursing action would be to:
 A. Wait until the client’s lab work is done.
 B. Not administer oxygen unless ordered by the physician.
 C. Administer oxygen at 2 L flow per minute.
 D. Administer oxygen at 10 L flow per minute and check the client’s nail beds.

Correct Answer: C. Administer oxygen at 2 L flow per minute.

Administer oxygen at 2 L/minute and no more, for if the client is emphysemic and receives
too high a level of oxygen, he will develop CO2 narcosis and the respiratory system will
cease to function. With prolonged oxygen therapy there is an increase in blood oxygen level,
which suppresses peripheral chemoreceptors; depresses ventilator drive and increase in
PCO2. high blood oxygen level may also disrupt the ventilation: perfusion balance (V/Q) and
cause an increase in dead space to tidal volume ratio and increase in PCO2.
. 39. Question
Immediately following a thoracentesis, which clinical manifestations indicate that a
complication has occurred and the physician should be notified?
 A. Serosanguineous drainage from the puncture site.
 B. Increased temperature and blood pressure.
 C. Increased pulse and pallor.
 D. Hypotension and hypothermia.

Correct Answer: C. Increased pulse and pallor

Increased pulse and pallor are symptoms associated with shock. A compromised venous
return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually,
no more than 1 L of fluid is removed at one time to prevent this from occurring.
. 40. Question
If a client continues to hypoventilate, the nurse will continually assess for a complication of:
 A. Respiratory acidosis
 B. Respiratory alkalosis
 C. Metabolic acidosis
 D. Metabolic alkalosis

Correct Answer: A. Respiratory acidosis

Respiratory acidosis represents an increase in the acid component, carbon dioxide, and an
increase in the hydrogen ion concentration (decreased pH) of the arterial blood. The
respiratory centers in the pons and medulla control alveolar ventilation. Chemoreceptors for
PCO2, PO2, and pH regulate ventilation. Central chemoreceptors in the medulla are sensitive
to changes in the pH level. A decreased pH level influences the mechanics of ventilation and
maintains proper levels of carbon dioxide and oxygen. When ventilation is disrupted, arterial
PCO2 increases and an acid-base disorder develops.
.
. 42. Question
Auscultation of a client’s lungs reveals crackles in the left posterior base. The nursing
intervention is to:
 A. Repeat auscultation after asking the client to deep breathe and cough.
 B. Instruct the client to limit fluid intake to less than 2000 ml/day.
 C. Inspect the client’s ankles and sacrum for the presence of edema.
 D. Place the client on bedrest in a semi-Fowler's position.

Correct Answer: A. Repeat auscultation after asking the client to deep breathe and
cough.
Although crackles often indicate fluid in the alveoli, they may also be related to
hypoventilation and will clear after a deep breath or a cough. Assess cough effectiveness and
productivity. Coughing is the most effective way to remove secretions. Pneumonia may cause
thick and tenacious secretions to patients.
. 43. Question
The most reliable index to determine the respiratory status of a client is to:
 A. Observe the chest rising and falling.
 B. Observe the skin and mucous membrane color.
 C. Listen and feel the air movement.
 D. Determine the presence of a femoral pulse.

Correct Answer: C. Listen and feel the air movement.

To check for breathing, the nurse places her ear and cheek next to the client’s mouth and nose
to listen and feel for air movement. During the inspection, the examiner should pay attention
to the pattern of breathing: thoracic breathing, thoracoabdominal breathing, coastal markings,
and use of accessory breathing muscles. The use of accessory breathing muscles (i.e.,
scalenes, sternocleidomastoid muscle, intercostal muscles) could point to excessive breathing
effort caused by pathologies.
. 45. Question
The physician has scheduled a client for a left pneumonectomy. The position that will most
likely be ordered postoperatively for his is the:
 A. Nonoperative side or back
 B. Operative side or back
 C. Back only
 D. Back or either side.

Correct Answer: B. Operative side or back

Following pneumonectomy, the client is positioned on the operative side to allow the fluid
left in the lung space to consolidate and avoid the heart from shifting to the operative side.
Pneumonectomy is defined as the surgical removal of the entire lung. Extrapleural
pneumonectomy is an expanded procedure that also involves resection of parietal and visceral
pleura, ipsilateral hemidiaphragm, pericardium, and mediastinal lymph nodes.
. 46. Question
Assessing a client who has developed atelectasis postoperatively, the nurse will most likely
find:
 A. A flushed face.
 B. Dyspnea and pain.
 C. Decreased temperature.
 D. Severe cough and no pain.
Correct Answer: B. Dyspnea and pain
Atelectasis is a collapse of the alveoli due to obstruction or hypoventilation. Clients become
short of breath, have a high temperature, and usually experience severe pain but do not have a
severe cough. The shortness of breath is a result of decreased oxygen-carbon dioxide
exchange at the alveolar level. Postoperative atelectasis typically occurs within 72 hours of
general anesthesia and is a well-known postoperative complication.
. 47. Question
A fifty-year-old client has a tracheostomy and requires tracheal suctioning. The first
intervention in completing this procedure would be to:
 A. Change the tracheostomy dressing.
 B. Provide humidity with a trach mask.
 C. Apply oral or nasal suction.
 D. Deflate the tracheal cuff.

Correct Answer: C. Apply oral or nasal suction.

Before deflating the tracheal cuff, the nurse will apply oral or nasal suction to the airway to
prevent secretions from falling into the lung. Dressing change and humidity do not relate to
suctioning. Airway suctioning is a procedure routinely done in most care settings, including
acute care, sub-acute care, long-term care, and home settings. Suctioning is performed when
the patient is unable to effectively move secretions from the respiratory tract.
. 50. Question
The best method of oxygen administration for client with COPD uses:
 A. Cannula
 B. Simple Face mask
 C. Non-rebreather mask
 D. Venturi mask

Correct Answer: D. Venturi mask

Venturi delivers controlled oxygen. An air-entrainment (also known as venturi) mask can
provide a pre-set oxygen to the patient using jet mixing. As the percent of inspired oxygen
increases using such a mask, the air-to-oxygen ratio decreases, causing the maximum
concentration of oxygen provided by an air-entrainment mask to be around 40%.
PART -2
. 1. Question
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma.
When teaching the patient about this drug, the nurse should explain that it may cause:
 A. Nasal congestion
 B. Nervousness
 C. Lethargy
 D. Hyperkalemia

Correct Answer: B. Nervousness

Albuterol may cause nervousness. The primary adverse effects of albuterol therapy are
tremors and nervousness, mostly seen in children who are 2 to 6 years of age, though can be
seen at any age. Tremors are the result of activation of the beta-2 receptors found on the
motor nerve terminals which increases intracellular cAMP. These side effects occur in
approximately one in every five patients. Other adverse effects of albuterol include tremor,
dizziness, headache, tachycardia, palpitations, hypertension, heartburn, nausea, vomiting and
muscle cramps.
. 2. Question
Miriam, a college student with acute rhinitis sees the campus nurse because of excessive
nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis,
nasal drainage normally is:
 A. Yellow
 B. Green
 C. Clear
 D. Gray

Correct Answer: C. Clear

Normally, nasal drainage in acute rhinitis is clear. Anterior rhinoscopy typically reveals
swelling of the nasal mucosa and thin, clear secretions. The inferior turbinates may take on a
bluish hue, and cobblestoning of the nasal mucosa may be present. On physical examination,
clinicians may notice mouth breathing, frequent sniffling and/or throat clearing, transverse
supra-tip nasal crease, and dark circles under the eyes (allergic shiners).
. 3. Question
A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory
alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
 A. Nausea or vomiting
 B. Abdominal pain or diarrhea
 C. Hallucinations or tinnitus
 D. Lightheadedness or paresthesia

Correct Answer: D. Lightheadedness or paresthesia

The patient with respiratory alkalosis may complain of lightheadedness or paresthesia
(numbness and tingling in the arms and legs). The exact history and physical exam findings
are highly variable as there are many pathologies that induce the pH disturbance. These may
include acute onset dyspnea, fever, chills, peripheral edema, orthopnea, weakness, confusion,
light-headedness, dizziness, anxiety, chest pain, wheezing, hemoptysis, trauma, history of
central line catheter, recent surgery, history of thromboembolic disease, history of asthma,
history of COPD, acute focal neurological signs, numbness, paresthesia, abdominal pain,
nausea, vomiting, tinnitus, or weight loss.
. 7. Question
On auscultation, which finding suggests a right pneumothorax?
 A. Bilateral inspiratory and expiratory crackles.
 B. Absence of breaths sound in the right thorax.
 C. Inspiratory wheezes in the right thorax.
 D. Bilateral pleural friction rub.

Correct Answer: B. Absence of breaths sound in the right thorax

In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore,
breath sounds in the affected lung field are absent. A pneumothorax is defined as a collection
of air outside the lung but within the pleural cavity. It occurs when air accumulates between
the parietal and visceral pleura inside the chest. The air accumulation can apply pressure on
the lung and make it collapse. The degree of collapse determines the clinical presentation of
pneumothorax. None of the other options are associated with pneumothorax.
. 9. Question
A male patient is admitted to the healthcare facility for treatment of chronic obstructive
pulmonary disease. Which nursing diagnosis is most important for this patient?
 A. Activity intolerance related to fatigue.
 B. Anxiety related to actual threat to health status.
 C. Risk for infection related to retained secretions.
 D. Impaired gas exchange related to airflow obstruction.

Correct Answer: D. Impaired gas exchange related to airflow obstruction.

A patient airway and an adequate breathing pattern are the top priority for any patient,
making “impaired gas exchange related to airflow obstruction” the most important nursing
diagnosis. Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%.
Pulse oximetry reading of 87% below may indicate the need for oxygen administration while
a pulse oximetry reading of 92% or higher may require oxygen titration. The other options
also may apply to this patient but less important.
. 10. Question
Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will
deviate toward the:
 A. Contralateral side in a simple pneumothorax.
 B. Affected side in a hemothorax.
 C. Affected side in a tension pneumothorax.
 D. Contralateral side in hemothorax.

Correct Answer: D. Contralateral side in hemothorax.

The trachea will shift according to the pressure gradients within the thoracic cavity. If there is
no significant air or fluid accumulation, the trachea will not shift. The pressure gradient
inside the thorax changes with a pneumothorax. Normally the pressure of the pleural space is
negative when compared to atmospheric pressure. When the chest wall expands outwards, the
lung also expands outwards due to surface tension between parietal and visceral pleura.
. 11. Question
After undergoing a left pneumonectomy, a female patient has a chest tube in place for
drainage. When caring for this patient, the nurse must:
 A. Monitor fluctuations in the water-seal chamber.
 B. Clamp the chest tube once every shift.
 C. Encourage coughing and deep breathing.
 D. Milk the chest tube every 2 hours.

Correct Answer: C. Encourage coughing and deep breathing

When caring for a patient who is recovering from a pneumonectomy, the nurse should
encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Assist
the patient with splinting painful areas when coughing, deep breathing. Supporting chest and
abdominal muscles makes coughing more effective and less traumatic.
. 12. Question
When caring for a male patient who has just had a total laryngectomy, the nurse should plan
to:
 A. Encourage oral feeding as soon as possible.
 B. Develop an alternative communication method.
 C. Keep the tracheostomy cuff fully inflated.
 D. Keep the patient flat in bed.

Correct Answer: B. Develop an alternative communication method.

A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the
nurse should plan to develop an alternative communication method. Assess the effectiveness
of nonverbal communication methods. The client may use hand signals, facial expressions,
and changes in body posture to communicate with others. However, others may have
difficulty in interpreting these nonverbal techniques. Each new method needs to be assessed
for effectiveness and altered as necessary.
. 13. Question
A male patient has a sucking stab wound to the chest. Which action should the nurse take
first?
 A. Drawing blood for a hematocrit and hemoglobin level.
 B. Applying a dressing over the wound and taping it on three sides.
 C. Preparing a chest tube insertion tray.
 D. Preparing to start an I.V. line.

Correct Answer: B. Applying a dressing over the wound and taping it on three sides.
The nurse immediately should apply a dressing over the stab wound and tape it on three sides
to allow air to escape and to prevent tension pneumothorax (which is more life-threatening
than an open chest wound). The nurse may use a first aid device called a chest seal or
improvise with the packaging sterile dressings coming in. Peel open the packaging and tape
the entire plastic portion over the wound.Only after covering and taping the wound should the
nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
. 14. Question
For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing
action best promotes adequate gas exchange?
 A. Encouraging the patient to drink three glasses of fluid daily.
 B. Keeping the patient in semi-Fowler's position.
 C. Using a high-flow venturi mask to deliver oxygen as prescribed.
 D. Administering a sedative, as prescribed.

Correct Answer: C. Using a high-flow venturi mask to deliver oxygen as prescribe

The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the
medullary center in the brain. As a result, low oxygen levels in the blood stimulate
respiration, and administering unspecified, unmonitored amounts of oxygen may depress
ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to
deliver a specified, controlled amount of oxygen consistently and accurately.
. 16. Question
For a female patient with chronic obstructive pulmonary disease, which nursing intervention
would help maintain a patent airway?
 A. Restricting fluid intake to 1,000 ml per day.
 B. Enforcing absolute bed rest.
 C. Teaching the patient how to perform controlled coughing.
 D. Administering prescribed sedatives regularly and in large amounts.

Correct Answer: C. Teaching the patient how to perform controlled coughing.

Controlled coughing helps maintain a patent airway by helping to mobilize and remove
secretions. Cough can be persistent but ineffective, especially if the patient is elderly, acutely
ill, or debilitated. Coughing is most effective in an upright or in a head-down position after
chest percussion.
. 17. Question
Nurse Lei, caring for a client with a pneumothorax and who has had a chest tube inserted,
continues gentle bubbling in the suction control chamber. What action is appropriate?
 A. Do nothing, because this is an expected finding.
 B. Immediately clamp the chest tube and notify the physician.
 C. Check for an air leak because the bubbling should be intermittent.
 D. Increase the suction pressure so that the bubbling becomes vigorous.

Correct Answer: A. Do nothing, because this is an expected finding.

Continuous gentle bubbling should be noted in the suction control chamber. Bubbling during
expiration reflects venting of pneumothorax (desired action). Bubbling usually decreases as
the lung expands or may occur only during expiration or coughing as the pleural space
diminishes.
. 18. Question
Nurse Maureen 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?
 A. Inform the physician.
 B. Continue to monitor the client.
 C. Reinforce the occlusive dressing.
 D. Encourage the client to deep breathe.
Correct Answer: B. Continue to monitor the client.
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 re-expanded.
. 19. Question
Nurse Reynolds 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:
 A. Call the physician.
 B. Place the tube in a bottle of sterile water.
 C. Immediately replace the chest tube system.
 D. Place a sterile dressing over the disconnection site.

Correct Answer: B. Place the tube in a bottle of sterile water.

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. Anchor thoracic catheter to the chest wall and provide
an extra length of tubing before turning or moving the patient. Prevents thoracic catheter
dislodgement or tubing disconnection and reduces pain and discomfort associated with
pulling or jarring of tubing.
. 20. Question
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct
the client to:
 A. Exhale slowly
 B. Stay very still
 C. Inhale and exhale quickly
 D. Perform the Valsalva maneuver

Correct Answer: D. Perform the Valsalva maneuver.

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.
. 22. Question
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The
nurse reports which of the following signs immediately if experienced by the client?
 A. Stridor
 B. Occasional pink-tinged sputum
 C. A few basilar lung crackles on the right
 D. Respiratory rate 24 breaths/min

Correct Answer: A. Stridor

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. Post-extubation stridor is uncommon and seen only
in less than 10% of unselected critically ill patients and correlates with increased rates of
reintubation, prolonged duration of mechanical ventilation, and longer length of ICU stay.
Options B, C, and D are not signs that require immediate notification of the physician.
.
. 23. Question
An emergency room nurse is assessing a male client who has sustained a blunt injury to the
chest wall. Which of these signs would indicate the presence of a pneumothorax in this
client?
 A. A low respiratory rate.
 B. Diminished breath sounds.
 C. The presence of a barrel chest.
 D. A sucking sound at the site of injury.

Correct Answer: B. Diminished breath sounds.

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 pneumothorax is defined as a
collection of air outside the lung but within the pleural cavity. It occurs when air accumulates
between the parietal and visceral pleura inside the chest. The air accumulation can apply
pressure on the lung and make it collapse.
. 24. Question
Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. Which of the following would the nurse expect to note on assessment of
this client?
 A. Hypocapnia
 B. A hyperinflated chest noted on the chest x-ray.
 C. Increased oxygen saturation with exercise.
 D. A widened diaphragm noted on the chest x-ray.

Correct Answer: B. A hyperinflated chest noted on the chest x-ray.

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. Hyperinflation of the lungs is often seen on
imaging studies and occurs due to air trapping from airway collapse during exhalation.
. 25. Question
An oxygen delivery system is prescribed for a male client with chronic obstructive
pulmonary disease to deliver a precise oxygen concentration. Which of the following types of
oxygen delivery systems would the nurse anticipate to be prescribed?
 A. Face tent
 B. Venturi mask
 C. Aerosol mask
 D. Tracheostomy collar

Correct Answer: B. Venturi mask

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. An air-entrainment (also known as venturi) mask can provide a pre-set
oxygen to the patient using jet mixing. As the percent of inspired oxygen increases using such
a mask, the air to oxygen ratio decreases, causing the maximum concentration of oxygen
provided by an air-entrainment mask to be around 40%. The face tent, aerosol mask, and
tracheostomy collar are also high-flow oxygen delivery systems but most often are used to
administer high humidity.
. 26. Question
Blessy, a community health nurse is conducting an educational session with community
members regarding tuberculosis. The nurse tells the group that one of the first symptoms
associated with tuberculosis is:
 A. Dyspnea
 B. Chest pain
 C. A bloody, productive cough.
 D. A cough with the expectoration of mucoid sputum.

Correct Answer: D. A cough with the expectoration of mucoid sputum

One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid
sputum. A chronic cough, hemoptysis, weight loss, low-grade fever, and night sweats are
some of the most common physical findings in pulmonary tuberculosis. Other options are late
symptoms and signify cavitation and extensive lung involvement.
. 27. Question
A nurse performs an admission assessment on a female client with a diagnosis of
tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this
diagnosis?
 A. Bronchoscopy
 B. Sputum culture
 C. Chest x-ray
 D. Tuberculin skin test

Correct Answer: B. Sputum culture

Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium
tuberculosis. Mycobacterial culture is the gold standard for diagnosis. Mycobacterial culture
should be performed on both the solid and liquid medium. Liquid media culture can detect
very low bacterial load and is considered a gold standard. Culture essential for drug
susceptibility testing. 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. Active tuberculosis is diagnosed by isolating
Mycobacterium tuberculosis complex bacilli from bodily secretions.
. 28. Question
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse
assesses the oxygen flow rate to ensure that it does not exceed:
 A. 1 L/min
 B. 2 L/min
 C. 6 L/min
 D. 10 L/min

Correct Answer: B. 2 L/min

Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing
hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen
levels rather than increased carbon dioxide levels, as is the case in a normal respiratory
system. Supplemental oxygen can successfully reach the alveoli in these lungs, which
prevents this vasoconstriction and thereby increases perfusion and improves gas exchange,
thus resulting in improvement of hypoxemia.
. 30. Question
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the
following would the nurse expect to note in the client?
 A. Pallor
 B. Low arterial PaO2
 C. Elevated arterial PaO2
 D. Decreased respiratory rate

Correct Answer: B. Low arterial PaO2

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. Despite 100% oxygen, patients have low oxygen saturation.
. 31. Question
A nurse is preparing to obtain a sputum specimen from a male client. Which of the following
nursing actions will facilitate obtaining the specimen?
 A. Limiting fluid.
 B. Having the client take deep breaths.
 C. Asking the client to spit into the collection container.
 D. Asking the client to obtain the specimen after eating.

Correct Answer: B. Having the client take deep breaths.

To obtain a sputum specimen, the client should rinse the mouth to reduce contamination,
breathe deeply, and then cough into a sputum specimen container. To cough deeply from the
lungs, the client might need to take three deep breaths before he coughs forcefully.
. 32. Question
Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following
signs, if noticed in the client, should be reported immediately to the physician?
 A. Dry cough
 B. Hematuria
 C. Bronchospasm
 D. Blood-streaked sputum

Correct Answer: C. Bronchospasm

If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for
several hours. The client should be assessed for signs of complications, which would include
cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and
dysrhythmias. Cardiac arrhythmias may also occur especially in patients with pre-existing
cardiac disease.
. 33. Question
A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the
nurse must limit the suctioning time to a maximum of:
 A. 1 minute
 B. 5 seconds
 C. 10 seconds
 D. 30 seconds

Correct Answer: C. 10 seconds

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. It is of
particular importance for patients with mechanical ventilators, endotracheal tube (ET)
intubations, tracheostomies, or other airway adjuncts. Clearance of airway secretions is a
normal process and is critical to the prevention of respiratory infections, atelectasis, and
preservation of airway patency.
. 34. Question
A nurse is suctioning fluids from a female client through an endotracheal tube. During the
suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which
if the following is the appropriate nursing intervention?
 A. Continue to suction.
 B. Notify the physician immediately.
 C. Stop the procedure and reoxygenate the client.
 D. Ensure that the suction is limited to 15 seconds.

Correct Answer: C. Stop the procedure and reoxygenate the client.

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.
. 35. Question
A male adult client is suspected of having a pulmonary embolism. A nurse assesses the client,
knowing that which of the following is a common clinical manifestation of pulmonary
embolism?
 A. Dyspnea
 B. Bradypnea
 C. Bradycardia
 D. Decreased respirations

Correct Answer: A. Dyspnea

The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia,
dyspnea, and chest pain. PE leads to impaired gas exchange due to obstruction of the
pulmonary vascular bed leading to a mismatch in the ventilation to perfusion ratio because
alveolar ventilation remains the same, but pulmonary capillary blood flow decreases,
effectively leading to dead space ventilation and hypoxemia.
. 38. Question
The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which
of the following should the nurse include in the teaching?
 A. Make inhalation longer than exhalation.
 B. Exhale through an open mouth.
 C. Use diaphragmatic breathing.
 D. Use chest breathing.

Correct Answer: C. Use diaphragmatic breathing.

In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to
strengthen the diaphragm and maximizes ventilation. When the client has COPD, air often
becomes trapped in the lungs, pushing down on the diaphragm. The neck and chest muscles
must then assume an increased share of the work of breathing. This can leave the diaphragm
weakened and flattened, causing it to work less efficiently.
. 39. Question
Which phrase is used to describe the volume of air inspired and expired with a normal
breath?
 A. Total lung capacity
 B. Forced vital capacity
 C. Tidal volume
 D. Residual volume

Correct Answer: C. Tidal volume

Tidal volume refers to the volume of air inspired and expired with a normal breath. Tidal
volume is the amount of air that moves in or out of the lungs with each respiratory cycle. It
measures around 500 mL in an average healthy adult male and approximately 400 mL in a
healthy female. It is a vital clinical parameter that allows for proper ventilation to take place.

. 40. Question
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial
oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the
manifestations?
 A. Simple mask
 B. Non-rebreather mask
 C. Face tent
 D. Nasal cannula

Correct Answer: B. Non-rebreather mask

A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as
100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of
FIO2. Non-rebreathing masks have a bag attached to the mask known as a reservoir bag,
which inhalation draws from to fill the mask through a one-way valve and features ports at
each side for exhalation, resulting in an ability to provide the patient with 100% oxygen at a
higher LPM flow rate.
. 41. Question
A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse
should instruct the client to notify the physician if a health concern occurs?
 A. Impaired color discrimination
 B. Increased urinary frequency
 C. Decreased hearing acuity
 D. Increased appetite

Correct Answer: C. Decreased hearing acuity

Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin
therapy. The client should notify the physician immediately if it occurs so that streptomycin
can be discontinued and an alternative drug can be prescribed. Ototoxicity and vestibular
impairment are often thought to be the hallmark of streptomycin toxicity. In extreme cases,
deafness may occur due to ototoxicity, thus caution must be exercised when combining
streptomycin with other potentially ototoxic drugs. The other options aren’t associated with
streptomycin.
. 42. Question
A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The
nurse should base her response on the fact that the:
 A. Area of redness is measured in 3 days and determines whether tuberculosis is present.
 B. Skin test doesn’t differentiate between active and dormant tuberculosis infection.
 C. Presence of a wheal at the injection site in 2 days indicates active tuberculosis.
 D. Test stimulates a reddened response in some clients and requires a second test in 3
months.

Correct Answer: B. Skin test doesn’t differentiate between active and dormant
tuberculosis infection.
The Mantoux test doesn’t differentiate between active and dormant infections. If a positive
reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide
more information. According to CDC, this test is performed using the ‘Mantoux technique,’
which is injecting 0.1 mL of a solution containing 5 units of tuberculin purified protein
derivative into the inner surface of the forearm through the intradermal route. It should be
administered two or more than 2 inches from the elbow, wrist, or any other injection site.
. 43. Question
A female adult client has a tracheostomy but doesn’t require continuous mechanical
ventilation. When weaning the client from the tracheostomy tube, the nurse initially should
plug the opening in the tube for:
 A. 15 to 60 seconds.
 B. 5 to 20 minutes.
 C. 30 to 40 minutes.
 D. 45 to 60 minutes.

Correct Answer: B. B. 5 to 20 minutes.

Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then
gradually lengthen this interval according to the client’s respiratory status. Tracheal plugging
is ordered by the doctor to help the client wean off an artificial airway. Plugging covers the
opening of the trach tube in the throat, and allowing her to breathe through her nose mouth.
Plugging will also help make the sound of her voice stronger.
. 44. Question
Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage
system. What should the nurse conclude?
 A. The system is functioning normally.
 B. The client has a pneumothorax.
 C. The system has an air leak.
 D. The chest tube is obstructed.

Correct Answer: C. The system has an air leak.

Constant bubbling in the chamber indicates an air leak and requires immediate intervention.
With suction applied, this indicates a persistent air leak that may be from a large
pneumothorax at the chest insertion site (patient-centered) or chest drainage unit (system-
centered).
. 45. Question
A black client with asthma seeks emergency care for acute respiratory distress. Because of
this client’s dark skin, the nurse should assess for cyanosis by inspecting the:
 A. Lips
 B. Mucous membranes
 C. Nail beds
 D. Earlobes

Correct Answer: B. Mucous membranes

Skin color doesn’t affect the mucous membranes. When the oxygen level has dropped only a
small amount, cyanosis may be hard to detect. In dark-skinned people, cyanosis may be
easier to see in the mucous membranes (lips, gums, around the eyes) and nails. The lips, nail
beds, and earlobes are less reliable indicators of cyanosis because they’re affected by skin
color.
. 46. Question
For a male client with an endotracheal (ET) tube, which nursing action is most essential?
 A. Auscultating the lungs for bilateral breath sounds.
 B. Turning the client from side to side every 2 hours.
 C. Monitoring serial blood gas values every 4 hours.
 D. Providing frequent oral hygiene.

Correct Answer: A. Auscultating the lungs for bilateral breath sounds.

For a client with an ET tube, the most important nursing action is auscultating the lungs
regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen
delivery. Adventitious breath sounds such as wheezes and crackles are an indication of
respiratory difficulties. Quick assessment allows for early detection of deterioration or
improvement. Although the other options are appropriate for this client, they’re secondary to
ensuring adequate oxygenation.
. 47. Question
The nurse assesses a male client’s respiratory status. Which observation indicates that the
client is experiencing difficulty breathing?
 A. Diaphragmatic breathing
 B. Use of accessory muscles
 C. Pursed-lip breathing
 D. Controlled breathing

Correct Answer: B. Use of accessory muscles

The use of accessory muscles for respiration indicates the client is having difficulty
breathing. Accessory muscles of respiration are muscles other than the diaphragm and
intercostal muscles that may be used for labored breathing. The sternocleidomastoid, spinal,
and neck muscles may be used as accessory muscles of respiration; their use is a sign of an
abnormal or labored breathing pattern. Diaphragmatic and pursed-lip breathing are two
controlled breathing techniques that help the client conserve energy.
. 50. Question
A male client with chronic obstructive pulmonary disease (COPD) is recovering from a
myocardial infarction. Because the client is extremely weak and can’t produce an effective
cough, the nurse should monitor closely for:
 A. Pleural effusion
 B. Pulmonary edema
 C. Atelectasis
 D. Oxygen toxicity

Correct Answer: C. Atelectasis

In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes
mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis.
Adults with COPD have extensive collateral ventilation secondary to airway destruction and
thus are less likely to develop resorption atelectasis in the presence of an obstructing lesion
(i.e., intrathoracic tumor). The use of high inspiratory oxygen concentration (high FiO2)
during induction and maintenance of general anesthesia also contributes to atelectasis via
absorption atelectasis.