MECHANICAL VENTILATION NCLEX EXAM
2 TEST BANK 2026 QUESTIONS AND
ANSWERS PRACTICE SOLUTION VERIFIED
CONTENT GRADED A+
⩥ 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? Answer: Negative
(Rationale)
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? Answer: It would not
increase the actual suction in the system but would cause more air to be
pulled through the air vent and suction chamber to the suction source.
,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? Answer:
Wheezes
Rationale:
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.
,⩥ The nurse is told that an assigned client will have a fenestrated
tracheostomy tube inserted. The nurse should provide the client with
which information about this type of tube? Answer: 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?
Answer: "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 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 apply. Answer: 50 mL of drainage in
the drainage-collection chamber
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 in a client returning to the nursing unit from the recovery
room; however, drainage of more than 70 to 100 mL/hr is considered
excessive and requires health care provider notification. The chest-tube
2 TEST BANK 2026 QUESTIONS AND
ANSWERS PRACTICE SOLUTION VERIFIED
CONTENT GRADED A+
⩥ 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? Answer: Negative
(Rationale)
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? Answer: It would not
increase the actual suction in the system but would cause more air to be
pulled through the air vent and suction chamber to the suction source.
,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? Answer:
Wheezes
Rationale:
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.
,⩥ The nurse is told that an assigned client will have a fenestrated
tracheostomy tube inserted. The nurse should provide the client with
which information about this type of tube? Answer: 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?
Answer: "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 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 apply. Answer: 50 mL of drainage in
the drainage-collection chamber
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 in a client returning to the nursing unit from the recovery
room; however, drainage of more than 70 to 100 mL/hr is considered
excessive and requires health care provider notification. The chest-tube
