NUR 111 LATEST 2026 STUDY GUIDE QUESTIONS AND
ANSWERS RATED A+
✔✔The nurse is caring for a neonate with respiratory distress. Which sign appears early
for the neonate with respiratory distress syndrome?
a. Tachypnea more than 60 breaths/minute.
b. Pale gray skin color.
c. Bilateral crackles.
d. Capillary filling time four seconds. - ✔✔a. Tachypnea more than 60 breaths/minute.
Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help
improve oxygenation.
Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't
treated.
A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms
persist and worsen.
Crackles occur as the respiratory distress progressively worsens.
✔✔The nursing is performing a respiratory assessment on a three-month-old. Which
technique will the nurse use to obtain an accurate respiratory rate?
a. Place the infant flat on the bed with the chest exposed.
b. Assess respirations after checking temperature and blood pressure.
c. Assess respirations while the infant is crying.
d. Assess respirations while the infant is being held by the parent. - ✔✔d. Assess
respirations while the infant is being held by the parent.
REMEMBER HOW THIS RELATES TO THE STAGES OF DEVELOPMENT AND
COMFORT
The most accurate respiratory rate is obtained before disturbing the infant or child. This
can often be done easily when the parent/caregiver is holding the child before any
clothing is removed.
The infant's respirations should be taken before disturbing the infant. Respiratory rate
often changes when infants or young children cry, feed, or become more active. They
also tend to breathe faster when they are anxious or scared. Count the respiratory rate
for a full minute to ensure accuracy. Infants' respirations are primarily diaphragmatic, so
count the abdominal movements. After 1 year of age, count the thoracic movements.
✔✔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. Ineffective breathing pattern related to alveolar hypoventilation.
,b. Weight loss related to COPD.
c. Imbalanced nutrition: Less than body requirements related to fatigue.
d. Activity intolerance related to dyspnea. - ✔✔c. Imbalanced 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. Encourage rest before
and after meals. COPD patients expend an extraordinary amount of energy simply on
breathing and require high caloric meals to maintain body weight and muscle
mass.Activity intolerance is a likely diagnosis but is not related to the client's nutritional
problems.Weight loss is not a nursing diagnosis.Ineffective breathing pattern may be a
problem, but this diagnosis does not specifically address the problem of weight loss and
nutrition described by the client.
✔✔A client is receiving oxygen through a nasal cannula. Which should the nurse do to
prevent skin breakdown around the patient's nares?
a. Remove the tubing for 15 minutes every 2 hours.
b. Adjust the cannula so it is comfortable.
c. Provide the client with oral hygiene whenever necessary.
d. Reposition the patient every 2 hours. - ✔✔b. Adjust the cannula so it is comfortable.
REMEMBER LEAST INVASIVE OPTION FIRST, REMOVING OXYGEN ENTIRELY
WOULD BE INVASIVE
If the cannula comfortably rests in the nares, it avoids pressure on the nares that can
cause skin breakdown. The cannula should not be too tight.
Although oral hygiene is important, it is mainly pressure that causes skin breakdown;
oral hygiene alone does not prevent skin breakdown.
Fifteen minutes is too long to remove oxygen from a client who needs oxygen.
Repositioning the client prevents pressure ulcers of dependent areas of the body but
does not prevent skin breakdown around the nares.
✔✔The nurse completes a focused respiratory assessment on an adult client. Which
abnormal respiratory assessment data will the nurse document in the electronic health
record? Select all that apply.
a. Dyspnea.
b. Inspiration half as long as expiration.
c. Respiratory rate 20 breaths per minute.
d. Asymmetrical chest expansion.
e. Intercostal retractions. - ✔✔a. Dyspnea
d. Asymmetrical chest expansion
e. Intercostal retractions.
, REMEMBER TO WATCH FOR WORDS LIKE ABNORMAL, C IS INCORRECT FOR
THIS QUESTION BECAUSE 12-20 IS THE NORMAL RANGE
Normal respiratory rate for an adult is 12-20.
Inspiration half as long as expiration is a normal finding for an adult.
✔✔The nurse provides teaching to the client about oxygen safety. Which statement by
the client about oxygen safety indicates an understanding of the teaching?
a. "I can apply petroleum jelly to my nose and lips when they are dry."
b. "I will store my oxygen tank in my car to keep it dry."
c. "I can smoke with my oxygen as long I do strike a match next to my tank."
d. "I will contact the local fire department to let them know I have oxygen in use at my
home." - ✔✔d. "I will contact the local fire department to let them know I have oxygen in
use at my home."
Oxygen safety in the home includes: Know NOT to smoke or be around people who are
smoking while using oxygen. Post "No Smoking—Oxygen In Use" signs on doors. Notify
local fire department and electric company of oxygen use in home. Never use paint
thinners, cleaning fluids, gasoline, aerosol sprays, and other flammable materials while
using oxygen. Keep all methods of oxygen delivery at least 15 ft away from matches,
candles, gas stove, or other source of flame, and 5 ft away from television, radio, and
other appliances. Keep oxygen tank out of direct sunlight. When traveling in automobile,
place oxygen tank on floor behind front seat. If traveling by airplane, notify air carrier of
need for oxygen at least 2 weeks in advance.
The client should not smoke with oxygen as it is flammable.
Petroleum jelly is flammable and should not be used by patients on oxygen.
Oxygen tanks should not be stored in cars and should be kept out of direct sunlight.
✔✔While auscultating the lungs of a client with asthma, the nurse hears a continuous,
high-pitched whistling sound on expiration. The nurse will document this sound as which
of the following?
a. Wheezes.
b. Crackles
c. Pleural friction rub.
d. Rhonchi. - ✔✔a. Wheezes.
Wheezes, usually heard on expiration, are continuous, musical, high pitched, and
whistle-like sounds caused by air passing through narrowed airways. Often, wheezes
are associated with asthma.
Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air
passes through secretions.
ANSWERS RATED A+
✔✔The nurse is caring for a neonate with respiratory distress. Which sign appears early
for the neonate with respiratory distress syndrome?
a. Tachypnea more than 60 breaths/minute.
b. Pale gray skin color.
c. Bilateral crackles.
d. Capillary filling time four seconds. - ✔✔a. Tachypnea more than 60 breaths/minute.
Tachypnea and expiratory grunting occur early in respiratory distress syndrome to help
improve oxygenation.
Poor capillary filling time, a later manifestation, occurs if signs and symptoms aren't
treated.
A pale gray skin color obscures earlier cyanosis as respiratory distress symptoms
persist and worsen.
Crackles occur as the respiratory distress progressively worsens.
✔✔The nursing is performing a respiratory assessment on a three-month-old. Which
technique will the nurse use to obtain an accurate respiratory rate?
a. Place the infant flat on the bed with the chest exposed.
b. Assess respirations after checking temperature and blood pressure.
c. Assess respirations while the infant is crying.
d. Assess respirations while the infant is being held by the parent. - ✔✔d. Assess
respirations while the infant is being held by the parent.
REMEMBER HOW THIS RELATES TO THE STAGES OF DEVELOPMENT AND
COMFORT
The most accurate respiratory rate is obtained before disturbing the infant or child. This
can often be done easily when the parent/caregiver is holding the child before any
clothing is removed.
The infant's respirations should be taken before disturbing the infant. Respiratory rate
often changes when infants or young children cry, feed, or become more active. They
also tend to breathe faster when they are anxious or scared. Count the respiratory rate
for a full minute to ensure accuracy. Infants' respirations are primarily diaphragmatic, so
count the abdominal movements. After 1 year of age, count the thoracic movements.
✔✔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. Ineffective breathing pattern related to alveolar hypoventilation.
,b. Weight loss related to COPD.
c. Imbalanced nutrition: Less than body requirements related to fatigue.
d. Activity intolerance related to dyspnea. - ✔✔c. Imbalanced 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. Encourage rest before
and after meals. COPD patients expend an extraordinary amount of energy simply on
breathing and require high caloric meals to maintain body weight and muscle
mass.Activity intolerance is a likely diagnosis but is not related to the client's nutritional
problems.Weight loss is not a nursing diagnosis.Ineffective breathing pattern may be a
problem, but this diagnosis does not specifically address the problem of weight loss and
nutrition described by the client.
✔✔A client is receiving oxygen through a nasal cannula. Which should the nurse do to
prevent skin breakdown around the patient's nares?
a. Remove the tubing for 15 minutes every 2 hours.
b. Adjust the cannula so it is comfortable.
c. Provide the client with oral hygiene whenever necessary.
d. Reposition the patient every 2 hours. - ✔✔b. Adjust the cannula so it is comfortable.
REMEMBER LEAST INVASIVE OPTION FIRST, REMOVING OXYGEN ENTIRELY
WOULD BE INVASIVE
If the cannula comfortably rests in the nares, it avoids pressure on the nares that can
cause skin breakdown. The cannula should not be too tight.
Although oral hygiene is important, it is mainly pressure that causes skin breakdown;
oral hygiene alone does not prevent skin breakdown.
Fifteen minutes is too long to remove oxygen from a client who needs oxygen.
Repositioning the client prevents pressure ulcers of dependent areas of the body but
does not prevent skin breakdown around the nares.
✔✔The nurse completes a focused respiratory assessment on an adult client. Which
abnormal respiratory assessment data will the nurse document in the electronic health
record? Select all that apply.
a. Dyspnea.
b. Inspiration half as long as expiration.
c. Respiratory rate 20 breaths per minute.
d. Asymmetrical chest expansion.
e. Intercostal retractions. - ✔✔a. Dyspnea
d. Asymmetrical chest expansion
e. Intercostal retractions.
, REMEMBER TO WATCH FOR WORDS LIKE ABNORMAL, C IS INCORRECT FOR
THIS QUESTION BECAUSE 12-20 IS THE NORMAL RANGE
Normal respiratory rate for an adult is 12-20.
Inspiration half as long as expiration is a normal finding for an adult.
✔✔The nurse provides teaching to the client about oxygen safety. Which statement by
the client about oxygen safety indicates an understanding of the teaching?
a. "I can apply petroleum jelly to my nose and lips when they are dry."
b. "I will store my oxygen tank in my car to keep it dry."
c. "I can smoke with my oxygen as long I do strike a match next to my tank."
d. "I will contact the local fire department to let them know I have oxygen in use at my
home." - ✔✔d. "I will contact the local fire department to let them know I have oxygen in
use at my home."
Oxygen safety in the home includes: Know NOT to smoke or be around people who are
smoking while using oxygen. Post "No Smoking—Oxygen In Use" signs on doors. Notify
local fire department and electric company of oxygen use in home. Never use paint
thinners, cleaning fluids, gasoline, aerosol sprays, and other flammable materials while
using oxygen. Keep all methods of oxygen delivery at least 15 ft away from matches,
candles, gas stove, or other source of flame, and 5 ft away from television, radio, and
other appliances. Keep oxygen tank out of direct sunlight. When traveling in automobile,
place oxygen tank on floor behind front seat. If traveling by airplane, notify air carrier of
need for oxygen at least 2 weeks in advance.
The client should not smoke with oxygen as it is flammable.
Petroleum jelly is flammable and should not be used by patients on oxygen.
Oxygen tanks should not be stored in cars and should be kept out of direct sunlight.
✔✔While auscultating the lungs of a client with asthma, the nurse hears a continuous,
high-pitched whistling sound on expiration. The nurse will document this sound as which
of the following?
a. Wheezes.
b. Crackles
c. Pleural friction rub.
d. Rhonchi. - ✔✔a. Wheezes.
Wheezes, usually heard on expiration, are continuous, musical, high pitched, and
whistle-like sounds caused by air passing through narrowed airways. Often, wheezes
are associated with asthma.
Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air
passes through secretions.
