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Saunders NCLEX Respiratory Questions - Answered with Rationales
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department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of wh...

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  • February 7, 2024
  • 70
  • 2023/2024
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Respiratory: Saunders NCLEX Review, Alterations in Respiratory Funct
Pulmonary Disorders Medications, Respiratory Disorders, Asthma, and COPD


1. 655. An emergency department nurse is caring for a client who sustained
a blunt injury to the chest wall. Which sign, if noted in the client, would
indicate the presence of a pneumothorax?

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: 2. Diminished breath sounds

Rationale:
The 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 present with tachypnea, cyanosis, diminished breath sounds,
and subcutaneous emphysema. There may also be hyperresonance on the
affected side. A sucking sound at the site of injury would be noted with an open
chest injury.
2. 656. A nurse is caring for a client hospitalized with acute exacerbation of
chronic obstructive pulmonary disease (COPD). Which of the following
would the nurse expect to note on an assessment of this client? Select all
that apply.

1. Hypocapnia
2. Dyspnea on exertion
3. Presence of a productive cough
4. Difficulty breathing while talking
5. Increased oxygen saturation with exercise
6. A shortened expiratory phase of respiration: 2. Dyspnea on exertion
3. Presence of a productive cough

Rationale:
Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on
exertion and at rest, oxygen desaturation with exercise, use of accessory muscles
of respiration, The chest x-ray will reveal a hyperinflated chest and a flattened
diaphragm if the disease is advanced. Pilmonary function tests will demonstrate
decreased vital capacity


,Respiratory: Saunders NCLEX Review, Alterations in Respiratory Funct
Pulmonary Disorders Medications, Respiratory Disorders, Asthma, and COPD


3. 657. A nurse instructs a client about 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?
1. Promote oxygen intake.
2. Strengthen the diaphragm.
3. Strengthen the intercostal muscles.
4. Promote carbon dioxide elimination.: 4. Promote carbon dioxide elimination.

Rationale:
Pursed lip breathing facilitates maximal expiration for clients with obstructive lung
disease. This type of breathing allows better expiration by increasing airway
pressure, which keeps air passages open during exhalation.
4. 658. The nurse is preparing a list of home care instructions for the client
who has been hospitalized and treated for tuberculosis. Which instructions
should the nurse will 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 have
already been exposed.
5. Cover the mouth and nose when coughing or sneezing and confine used
tissues to plastic bags.
6. When one sputum culture is negative, the client is no longer considered
infectious and can usually return to his or her former employment.: 1.
Activities should be resumed gradually.
3. A sputum culture is needed every 2 to 4 weeks once medication therapy is
initiated.
4. Respiratory isolation is not necessary because family members have already
been exposed.




,Respiratory: Saunders NCLEX Review, Alterations in Respiratory Funct
Pulmonary Disorders Medications, Respiratory Disorders, Asthma, and COPD


5. Cover the mouth and nose when coughing or sneezing and confine used
tissues to plastic bags.


Rationale:
The nurse should provide the client and family with information about tuberculosis
and allay concerns about the contagious aspect of the infection. The client is to
follow the medication regimen exactly as prescribed and always to have a supply
of the medication on hand. The client is advised of the side effects of the
medication and ways of minimizing them to ensure compliance. The client is
reassured that, after 2 to 3 weeks of medication therapy, it is unlikely that the
client will infect anyone. The client is also informed that activities should be
resumed gradually 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. The client and family are informed that respiratory isolation
is not necessary, because family members have already been exposed. The client
is instructed about thorough handwashing and to cover the mouth and nose when
coughing or sneezing and confine used tissues to plastic bags. The client is
informed that a sputum culture is needed every 2 to 4 weeks once medication
therapy is initiated and, when the results of three sputum cultures are negative,
the client is no longer considered infectious and can usually return to his or her
former employment.
5. 659. The nurse is caring for a client after a bronchoscopy and biopsy.
Which finding, if noted in the client,should be reported immediately to the
healthcare provider?

1.Dry cough
2.Hematuria
3.Bronchospasm
4.Blood-streaked sputum: 3.Bronchospasm

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/symptoms of complications,
which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis,



, Respiratory: Saunders NCLEX Review, Alterations in Respiratory Funct
Pulmonary Disorders Medications, Respiratory Disorders, Asthma, and COPD


hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this
procedure
6. 660.
Thenurseispreparingtosuctionaclientviaatracheostomytube.Thenurseshould
plantolimitthesuctioningtimetoamaximumofwhichtimeperiod?

1. 1 minute
2. 5 seconds
3. 10 seconds
4. 30 seconds: 3. 10 seconds

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
10seconds
7. 661. The nurse is suctioning a client via an endotracheal tube. During the
suctioning procedure, the nurse notes on the monitor that the heart rate is
decreasing. Which nursing intervention is most appropriate?

1.Continue to suction.
2.Notify the healthcare provider immediately.
3.Stop the procedure and reoxygenate the client. 4.Ensure that the suction is
limited to 15 seconds: 3.Stop the procedure and reoxygenate the client.

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 adverse effects develop, especially cardiac irregularities, the
procedure is stopped and the client is reoxygenated.
8. 662. The nurse is assessing the respiratory status of a client who has
suffered a fractured rib. The nurse should expect to note which finding?

1.Slow deep respirations

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