1
Respiratory - Saunders NCLEX-PN
Examination 6th Edition Questions
and Answers (100% Correct
Answers) Already Graded A+
The nurse is caring for a client with laryngitis. Which
© 2026 Assignment
interventions should the nurse implement? Select all that
apply. Ans: Discourage smoking
Guru01 - Stuvia
Expert
Use a room humidifier
Use lozenges that contain a topical anesthetic agents
(Rationale)
Smoking irritates the throat so the client is discouraged from
smoking. A humidifier will prevent a dry nose and throat.
Lozenges with a topical anesthetic agent will decrease throat
discomfort. Voice rest means not talking at all, even
whispering. There should be a sign on the intercom indicating
voice rest and going to the client's room.
The nurse is reading the results of a Mantoux tuberculin skin
test on a client with no documented health problems. The site
has no induration and a 1-mm area of ecchymosis. Which
interpretation should the nurse make of these results? Ans:
Negative
(Rationale)
, 2
A positive Mantoux tuberculin skin test reading has an
induration measuring 10 mm or more in diameter and
indicates exposure to tuberculosis. A small area of ecchymosis
is insignificant and is probably related to injection technique.
Therefore, the remaining options are incorrect.
A client has a chest tube that is attached to a chest drainage
system. The client asks the nurse, "Can the tube come out
faster if you turn the wall suction up higher?" The nurse's
response is based on which fact with regard to turning up the
wall suction? Ans: It would not increase the actual suction in
© 2026 Assignment
the system but would cause more air to be pulled through the
air vent and suction chamber to the suction source.
Guru01 - Stuvia
Expert
Rationale:
The amount of suction in the chest drainage system is
controlled by the amount of sterile water that is poured into
the suction control chamber. In a dry suction system, this is
accomplished by regulating the suction dial on the chest
drainage device. Increasing the wall suction will only cause
vigorous bubbling in the suction chamber, as more air is
pulled through the air vent and suction control chamber to the
suction source. The only effect this would have is to increase
the rate of water evaporation from the suction control
chamber, so sterile water would have to be added to the
system more frequently.
The nurse is listening to the client's breath sounds and hears
musical whistling noises on inspiration and expiration
scattered throughout the right lung fields. How should the
nurse interpret these noises? Ans: Wheezes
Rationale:
, 3
Wheezes are musical noises heard on inspiration, expiration,
or both. They are the result of narrowed air passages. Crackles
have the sound that is heard when a few strands of hair are
rubbed together near the ear, and indicate fluid in the alveoli.
Rhonchi are usually heard on expiration when there is
excessive production of mucus, which accumulates in the air
passages. A pleural friction rub is characterized by sounds that
are described as creaking, groaning, or grating in quality. The
sounds are localized over an area of inflammation of the
pleura and may be heard in both the inspiratory and expiratory
phases of the respiratory cycle.
© 2026 Assignment
The nurse is told that an assigned client will have a fenestrated
tracheostomy tube inserted. The nurse should provide the
Guru01 - Stuvia
client with which information about this type of tube? Ans:
Expert
Enables the client to speak
Rationale:
A fenestrated tube has a small opening in the outer cannula
that allows some air to escape through the larynx; this type of
tube enables the client to speak. Options 2, 3, and 4 are
incorrect with regard to this type of tube.
Which statement by the client indicates a need for further
teaching regarding the reinforced home care instructions for
acute sinusitis? Ans: "I will need surgery to drain my
sinuses."
Rationale:
The nurse provides instructions to the client regarding
measures to promote sinus drainage, comfort, and resolution
of the infection. The nurse instructs the client to apply heat in
the form of hot wet packs over the affected sinuses to promote
comfort and help resolve the infection. Large amounts of
, 4
fluids are important to help liquefy secretions. Sleeping with
the head of the bed elevated to a 45-degree angle will assist in
promoting drainage. Surgery may be performed to improve
drainage in chronic conditions if other measures are not
helpful, but it is not usually a treatment measure for acute
sinusitis.
The nurse is assisting with monitoring the functioning of a
chest-tube drainage system in a client who just returned from
the recovery room after a thoracotomy with wedge resection.
Which findings should the nurse expect to note? Select all that
© 2026 Assignment
apply. Ans: 50 mL of drainage in the drainage-collection
chamber
Guru01 - Stuvia
Expert
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion
site.
Fluctuation of water in the tube of the water-seal chamber
during inhalation and exhalation
(Rationale)
The bubbling of water in the water-seal chamber indicates air
drainage from the client. This is usually seen when
intrathoracic pressure is greater than atmospheric pressure,
and it may occur during exhalation, coughing, or sneezing.
Excessive bubbling in the water-seal chamber may indicate an
air leak, which is an unexpected finding. The fluctuation of
water in the tube in the water-seal chamber during inhalation
and exhalation is expected. An absence of fluctuation may
indicate that the chest tube is obstructed, the lung has re-
expanded, or no more air is leaking into the pleural space.
Gentle (not vigorous) bubbling should be noted in the suction-
control chamber. A total of 50 mL of drainage is not excessive
Respiratory - Saunders NCLEX-PN
Examination 6th Edition Questions
and Answers (100% Correct
Answers) Already Graded A+
The nurse is caring for a client with laryngitis. Which
© 2026 Assignment
interventions should the nurse implement? Select all that
apply. Ans: Discourage smoking
Guru01 - Stuvia
Expert
Use a room humidifier
Use lozenges that contain a topical anesthetic agents
(Rationale)
Smoking irritates the throat so the client is discouraged from
smoking. A humidifier will prevent a dry nose and throat.
Lozenges with a topical anesthetic agent will decrease throat
discomfort. Voice rest means not talking at all, even
whispering. There should be a sign on the intercom indicating
voice rest and going to the client's room.
The nurse is reading the results of a Mantoux tuberculin skin
test on a client with no documented health problems. The site
has no induration and a 1-mm area of ecchymosis. Which
interpretation should the nurse make of these results? Ans:
Negative
(Rationale)
, 2
A positive Mantoux tuberculin skin test reading has an
induration measuring 10 mm or more in diameter and
indicates exposure to tuberculosis. A small area of ecchymosis
is insignificant and is probably related to injection technique.
Therefore, the remaining options are incorrect.
A client has a chest tube that is attached to a chest drainage
system. The client asks the nurse, "Can the tube come out
faster if you turn the wall suction up higher?" The nurse's
response is based on which fact with regard to turning up the
wall suction? Ans: It would not increase the actual suction in
© 2026 Assignment
the system but would cause more air to be pulled through the
air vent and suction chamber to the suction source.
Guru01 - Stuvia
Expert
Rationale:
The amount of suction in the chest drainage system is
controlled by the amount of sterile water that is poured into
the suction control chamber. In a dry suction system, this is
accomplished by regulating the suction dial on the chest
drainage device. Increasing the wall suction will only cause
vigorous bubbling in the suction chamber, as more air is
pulled through the air vent and suction control chamber to the
suction source. The only effect this would have is to increase
the rate of water evaporation from the suction control
chamber, so sterile water would have to be added to the
system more frequently.
The nurse is listening to the client's breath sounds and hears
musical whistling noises on inspiration and expiration
scattered throughout the right lung fields. How should the
nurse interpret these noises? Ans: Wheezes
Rationale:
, 3
Wheezes are musical noises heard on inspiration, expiration,
or both. They are the result of narrowed air passages. Crackles
have the sound that is heard when a few strands of hair are
rubbed together near the ear, and indicate fluid in the alveoli.
Rhonchi are usually heard on expiration when there is
excessive production of mucus, which accumulates in the air
passages. A pleural friction rub is characterized by sounds that
are described as creaking, groaning, or grating in quality. The
sounds are localized over an area of inflammation of the
pleura and may be heard in both the inspiratory and expiratory
phases of the respiratory cycle.
© 2026 Assignment
The nurse is told that an assigned client will have a fenestrated
tracheostomy tube inserted. The nurse should provide the
Guru01 - Stuvia
client with which information about this type of tube? Ans:
Expert
Enables the client to speak
Rationale:
A fenestrated tube has a small opening in the outer cannula
that allows some air to escape through the larynx; this type of
tube enables the client to speak. Options 2, 3, and 4 are
incorrect with regard to this type of tube.
Which statement by the client indicates a need for further
teaching regarding the reinforced home care instructions for
acute sinusitis? Ans: "I will need surgery to drain my
sinuses."
Rationale:
The nurse provides instructions to the client regarding
measures to promote sinus drainage, comfort, and resolution
of the infection. The nurse instructs the client to apply heat in
the form of hot wet packs over the affected sinuses to promote
comfort and help resolve the infection. Large amounts of
, 4
fluids are important to help liquefy secretions. Sleeping with
the head of the bed elevated to a 45-degree angle will assist in
promoting drainage. Surgery may be performed to improve
drainage in chronic conditions if other measures are not
helpful, but it is not usually a treatment measure for acute
sinusitis.
The nurse is assisting with monitoring the functioning of a
chest-tube drainage system in a client who just returned from
the recovery room after a thoracotomy with wedge resection.
Which findings should the nurse expect to note? Select all that
© 2026 Assignment
apply. Ans: 50 mL of drainage in the drainage-collection
chamber
Guru01 - Stuvia
Expert
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion
site.
Fluctuation of water in the tube of the water-seal chamber
during inhalation and exhalation
(Rationale)
The bubbling of water in the water-seal chamber indicates air
drainage from the client. This is usually seen when
intrathoracic pressure is greater than atmospheric pressure,
and it may occur during exhalation, coughing, or sneezing.
Excessive bubbling in the water-seal chamber may indicate an
air leak, which is an unexpected finding. The fluctuation of
water in the tube in the water-seal chamber during inhalation
and exhalation is expected. An absence of fluctuation may
indicate that the chest tube is obstructed, the lung has re-
expanded, or no more air is leaking into the pleural space.
Gentle (not vigorous) bubbling should be noted in the suction-
control chamber. A total of 50 mL of drainage is not excessive
