1. A male 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:
a. 10 mcg/mL
b. 12 mcg/mL
c. 15 mcg/mL
2. Nurse Kim is 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?
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 bubbling becomes vigorous.
3. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult 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.
4. The nurse caring for a male 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 the sterile dressing over the disconnection site.
5. Nurse Paul 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.
6. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
a. Call the physician to reinsert the tube.
b. Grasp the retention sutures to spread the opening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.
7. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
b. Occasional pink-tinged sputum
c. A few basilar lung crackles on the right
d. Respiratory rate of 24 breaths/min
8. An emergency room nurse is assessing a female 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
b. Diminished breathe sounds
c. The presence of a barrel chest
d. A sucking sound at the site of injury
9. A nurse is caring for a male 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?
b. A hyperinflated chest noted on the chest x-ray
c. Increase oxygen saturation with exercise
d. A widened diaphragm noted on the chest x-ray
10. 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:
b. Chest pain
c. A bloody, productive cough
d. A cough with the expectoration of mucoid sputum
11. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis?
b. Sputum culture
c. Chest x-ray
d. Tuberculin skin test
12. The 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 the tuberculosis is transmitted by:
a. Hand and mouth
b. The airborne route
c. The fecal-oral route
d. Blood and body fluids
13. 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
14. A nurse instructs a female 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:
a. Promote oxygen intake.
b. Strengthen the diaphragm.
c. Strengthen the intercostal muscles.
d. Promote carbon dioxide elimination.
15. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?
a. Limiting fluids
b. Having the clients take three deep breaths
c. Asking the client to split into the collection container
d. Asking the client to obtain the specimen after eating
16. A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians?
a. Dry cough
d. Blood-streaked sputum
17. 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
18. 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 of 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.
19. An unconscious male 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:
a. Metabolic acidosis
b. Respiratory acidosis
c. Overcompensated respiratory acidosis
d. Combined respiratory and metabolic acidosis
20. A female 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?
d. Decreased respiratory
21. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching?
a. Inhales the mist and quickly exhales
b. Removes the cap and shakes the inhaler well before use
c. Presses the canister down with the finger as he breathes in
d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
22. A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?
a. Administering atropine intravenously
b. Administering small doses of midazolam (Versed)
c. Encouraging additional fluids for the next 24 hours
d. Ensuring the return of the gag reflex before offering food or fluids
23. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following?
a. Slow deep respirations
b. Rapid deep respirations
c. Paradoxical respirations
d. Pain, especially with inspiration
24. A female client with chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest?
c. Paradoxical chest movement
d. Dyspnea, especially on exhalation
25. A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:
a. Right pneumothorax
b. Pulmonary embolism
c. Displaced endotracheal tube
d. Acute respiratory distress syndrome
26. A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to:
a. Inhale quickly
b. Inhale through the nose
c. Hold the breath after inhalation
d. Take two inhalations during one breath
27. A nurse is assessing a female 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?
a. Bilateral wheezing
b. Inspiratory crackles
c. Intercostal retractions
d. Increased respiratory rate
28. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is:
a. High and expected
b. Low and unexpected
c. Normal and expected
d. Uncertain and unexpected
29. A nurse is assessing a male client with chronic airflow limitations and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitations?
b. Bronchial asthma
c. Chronic obstructive bronchitis
d. Bronchial asthma and bronchitis
30. A nurse is caring for a female 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?
b. High-grade fever
c. Chills and night sweats
d. Anorexia and weight loss
Answers and Rationale will be posted soon…
More nclex sample questions coming up.