Gas Exchange and oxygena on assessment Basic
Fundamental NClex prac ce ques ons
A nurse is assessing a client who is receiving oxygen therapy. The nurse should iden fy that
which of the following findings can indicate oxygen toxicity?
a. Hypertension
b. ringing in the ears
c. fever
d. dilated pupils
B
- The nurse should iden fy that ringing in the ears, as well as headache, disorienta on, and
muscle twitching can indicate oxygen toxicity.
A nurse is assessing a client who has COPD. The nurse should iden fy that which of the
following is an expected finding?
a. Jugular vein distension
b. Clubbing of the fingers
c. Heart murmur
d. Paradoxical breathing
B
- The nurse should iden fy that clubbing of the fingers is an expected finding for a client who
has chronic pulmonary disease, such as COPD
A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve.
Which of the following findings should the nurse expect?
a. Regurgita on
b. Stenosis
c. Muscle atrophy
d. Hypotension
B
- The nurse should expect a client who has heart disease and a narrowed valve to have stenosis.
Stenosis is a narrowing or s ffening of the heart valve that causes backflow of the blood.
A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery
devices should the nurse expect to use?
a. Nasal cannula
b. Nonrebreather mask
, c. Par al rebreather mask
d. Simple face mask
A
- The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be
delivered at low concentra ons of 1 to 4 L/min.
A nurse is ausculta ng a clients heart sounds and hears a low-pitched whooshing or blowing
sound over the apex of the heart. The nurse should iden fy that this indicates which of the
following ?
a. Tachycardia
b. Murmur
c. Gallop
d. Stroke volume
B
- A whooshing or blowing sound indicates a murmur and can be low, medium, or high pitched
(BRUIT)
A nurse is assessing a client who is being discharged. The nurse notes the client has regular and
quiet breathing. The nurse should iden fy this breathing pa9ern as which of the following?
a. Normal breathing
b. Kussmaul breathing
c. Cheyne-stokes breathing
d. Apnea
A
- A normal breathing pa9ern is regular, quiet, and shows no manifesta ons of discomfort
A nurse is providing teaching for a client who has a new prescrip on for an incen ve spirometer.
Which of the following instruc ons should the nurse include?
a. "Exhale into the incen ve spirometer"
b. "Use the incen ve spirometer every hour while awake"
c. :"Hold your breath for 10 seconds when using the incen ve spirometer"
d. "Use the incen ve spirometer two mes each session."
B
- The nurse should instruct the pa ent to use the incen ve spirometer every hour while awake
to promote lung expansion and mobilize secre ons
(Prevents atelectasis)
Fundamental NClex prac ce ques ons
A nurse is assessing a client who is receiving oxygen therapy. The nurse should iden fy that
which of the following findings can indicate oxygen toxicity?
a. Hypertension
b. ringing in the ears
c. fever
d. dilated pupils
B
- The nurse should iden fy that ringing in the ears, as well as headache, disorienta on, and
muscle twitching can indicate oxygen toxicity.
A nurse is assessing a client who has COPD. The nurse should iden fy that which of the
following is an expected finding?
a. Jugular vein distension
b. Clubbing of the fingers
c. Heart murmur
d. Paradoxical breathing
B
- The nurse should iden fy that clubbing of the fingers is an expected finding for a client who
has chronic pulmonary disease, such as COPD
A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve.
Which of the following findings should the nurse expect?
a. Regurgita on
b. Stenosis
c. Muscle atrophy
d. Hypotension
B
- The nurse should expect a client who has heart disease and a narrowed valve to have stenosis.
Stenosis is a narrowing or s ffening of the heart valve that causes backflow of the blood.
A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery
devices should the nurse expect to use?
a. Nasal cannula
b. Nonrebreather mask
, c. Par al rebreather mask
d. Simple face mask
A
- The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be
delivered at low concentra ons of 1 to 4 L/min.
A nurse is ausculta ng a clients heart sounds and hears a low-pitched whooshing or blowing
sound over the apex of the heart. The nurse should iden fy that this indicates which of the
following ?
a. Tachycardia
b. Murmur
c. Gallop
d. Stroke volume
B
- A whooshing or blowing sound indicates a murmur and can be low, medium, or high pitched
(BRUIT)
A nurse is assessing a client who is being discharged. The nurse notes the client has regular and
quiet breathing. The nurse should iden fy this breathing pa9ern as which of the following?
a. Normal breathing
b. Kussmaul breathing
c. Cheyne-stokes breathing
d. Apnea
A
- A normal breathing pa9ern is regular, quiet, and shows no manifesta ons of discomfort
A nurse is providing teaching for a client who has a new prescrip on for an incen ve spirometer.
Which of the following instruc ons should the nurse include?
a. "Exhale into the incen ve spirometer"
b. "Use the incen ve spirometer every hour while awake"
c. :"Hold your breath for 10 seconds when using the incen ve spirometer"
d. "Use the incen ve spirometer two mes each session."
B
- The nurse should instruct the pa ent to use the incen ve spirometer every hour while awake
to promote lung expansion and mobilize secre ons
(Prevents atelectasis)
