Respiratory Disorders NCLEX Questions
With Guaranteed Pass Solutions.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
ADrawing blood for a hematocrit and hemoglobin level
BApplying a dressing over the wound and taping it on three sides
CPreparing a chest tube insertion tray
DPreparing to start an I.V. line - Answer B
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary
disease. Which nursing diagnosis is most important for this patient?
AActivity intolerance related to fatigue
BAnxiety related to actual threat to health status
CRisk for infection related to retained secretions
DImpaired gas exchange related to airflow obstruction - Answer D
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
BAbdominal pain or diarrhea
CHallucinations or tinnitus
DLightheadedness or paresthesia - Answer D. The patient with respiratory alkalosis may complain of
lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting,
abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are
associated with respiratory alkalosis or any other acid-base imbalance.
Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's
central nervous system (CNS) effects, it is not recommended for:
A Patients with an acute asthma attack
B Patients with narcolepsy
, C Patients under age 6
D Elderly patients - Answer D. Ephedrine is not recommended for elderly patients, who are particularly
susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as
increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its
bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for
narcolepsy. It can be administered to children age 2 and older.
A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's
condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated.
When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for
the cause. Which condition triggers the high pressure alarm?
A Kinking of the ventilator tubing
B A disconnected ventilator tube
C An endotracheal cuff leak
D A change in the oxygen concentration without resetting the oxygen level alarm - Answer A.
Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or
pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and
the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an
endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without
resetting the oxygen level alarm would tigger the oxygen alarm.
A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg
I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?
A Leg movement
B Finger movement
C Lip movement
D Fighting the ventilator - Answer D.Pancuronium, a nondepolarizing blocking agent, is used for muscle
relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and
paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign
that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V.
every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not
used to determine the need for another dose.
On auscultation, which finding suggests a right pneumothorax?
A Bilateral inspiratory and expiratory crackles
With Guaranteed Pass Solutions.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
ADrawing blood for a hematocrit and hemoglobin level
BApplying a dressing over the wound and taping it on three sides
CPreparing a chest tube insertion tray
DPreparing to start an I.V. line - Answer B
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary
disease. Which nursing diagnosis is most important for this patient?
AActivity intolerance related to fatigue
BAnxiety related to actual threat to health status
CRisk for infection related to retained secretions
DImpaired gas exchange related to airflow obstruction - Answer D
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
BAbdominal pain or diarrhea
CHallucinations or tinnitus
DLightheadedness or paresthesia - Answer D. The patient with respiratory alkalosis may complain of
lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting,
abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are
associated with respiratory alkalosis or any other acid-base imbalance.
Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's
central nervous system (CNS) effects, it is not recommended for:
A Patients with an acute asthma attack
B Patients with narcolepsy
, C Patients under age 6
D Elderly patients - Answer D. Ephedrine is not recommended for elderly patients, who are particularly
susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as
increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its
bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for
narcolepsy. It can be administered to children age 2 and older.
A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's
condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated.
When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for
the cause. Which condition triggers the high pressure alarm?
A Kinking of the ventilator tubing
B A disconnected ventilator tube
C An endotracheal cuff leak
D A change in the oxygen concentration without resetting the oxygen level alarm - Answer A.
Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or
pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and
the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an
endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without
resetting the oxygen level alarm would tigger the oxygen alarm.
A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg
I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?
A Leg movement
B Finger movement
C Lip movement
D Fighting the ventilator - Answer D.Pancuronium, a nondepolarizing blocking agent, is used for muscle
relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and
paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign
that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V.
every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not
used to determine the need for another dose.
On auscultation, which finding suggests a right pneumothorax?
A Bilateral inspiratory and expiratory crackles
