NCLEX Practice Questions and Answers Saunders - Respiratory System 2021 with complete solution
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NCLEX Practice
The emergency department nurse is assessing a client who has sustained a
blunt injury to the chest wall. Which finding would indicate the presence of a
pneumothorax in this client?
1. A low respiratory rate
2. Diminished breath sounds
3. The presence of a barrel chest
4. A sucking sound at th...
nclex practice questions and answers saunders respiratory system
the emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall which finding would indicate
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NCLEX Practice Questions and Answers
Saunders - Respiratory System
1. The emergency department nurse is assessing a client who has
sustained a blunt injury to the chest wall. Which finding would indicate
the presence of a pneumothorax in this client?
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
Correct answer- 2. Diminished breath sounds
Rationale: This client has sustained a blunt or 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.
2. The nurse is caring for a client hospitalized with acute exacerbation of
chronic obstructive pulmonary disease. Which finding would the nurse
expect to note on assessment of this client? Select all that apply.
1. Hypocapnia
2. A hyperinflated chest noted on the chest x-ray
3. Decreased oxygen saturation with mild exercise
4. A widened diaphragm noted on the chest x-ray
5. Pulmonary function tests that demonstrate increased vital capacity
Correct answer- 2. A hyperinflated chest noted on the chest x-ray
Decreased oxygen saturation with mild exercise
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. Pulmonary
function tests will demonstrate decreased vital capacity.
3. The 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 promote which outcome?
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.
4. The nurse is preparing a list of home care instructions for a client who
has been hospitalized and treated for tuberculosis. Which instructions
should the nurse include on the list? Select all that apply.
1. Activities should be resumed gradually.
2. Avoid contact with other individuals, except family members, for at
least 6 months.
3. A sputum culture is needed every 2 to 4 weeks once medication
therapy is initiated.
4. Respiratory isolation is not necessary because family members 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.
Correct answer- 1. Activities should be resumed gradually.
3. A sputum culture is needed every 2 to 4 weeks once medication
therapy is initiated.
Respiratory isolation is not necessary because family members already
have been exposed.
Cover the mouth and nose when coughing or sneezing and put used
tissues in plastic bags.
Rationale: The nurse should provide the client and family with
information about tuberculosis and allay concerns about the
contagious aspect of the infection. 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
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