MedSurg NCLEX -Test 3 - Questions
for test respiratory All Solved
Correctly 2026 Edition.
A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests - Answer ANS: B
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining a
comprehensive health history or full physical examination is unnecessary until the acute distress
has resolved. Brief questioning and a focused physical assessment should be done rapidly to
help determine the cause of the distress and suggest treatment. Checking for allergies is
important, but it is not appropriate to complete the entire admission database at this time. The
initial respiratory assessment must be completed before any diagnostic tests or interventions
can be ordered.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should
the nurse position the patient?
a. Supine with the head of the bed elevated 30 degrees
b. In a high-Fowler's position with the left arm extended
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table - Answer ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to collect at
the lung bases, and expands the intercostal space so that access to the pleural space is easier.
The other positions would increase the work of breathing for the patient and make it more
difficult for the health care provider performing the thoracentesis.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm
Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure - Answer ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low
oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
, On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during
inhalation in the lower third of both lungs. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes - Answer ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-
pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory
cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating
sounds that are usually heard during both inspiration and expiration.
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by
the nurse is most appropriate?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.
d. Notify the health care provider about blood-tinged mucus. - Answer ANS: B
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is
used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the
return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged
mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and
the head of the bed does not need to be in the high-Fowler's position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart
failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration heard on inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration - Answer
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are
continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a
series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are
continuous high-pitched musical sounds on inspiration and expiration.
The nurse observes a student who is listening to a patient's lungs who is having no problems
with breathing. Which action by the student indicates a need to review respiratory assessment
skills?
for test respiratory All Solved
Correctly 2026 Edition.
A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests - Answer ANS: B
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining a
comprehensive health history or full physical examination is unnecessary until the acute distress
has resolved. Brief questioning and a focused physical assessment should be done rapidly to
help determine the cause of the distress and suggest treatment. Checking for allergies is
important, but it is not appropriate to complete the entire admission database at this time. The
initial respiratory assessment must be completed before any diagnostic tests or interventions
can be ordered.
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should
the nurse position the patient?
a. Supine with the head of the bed elevated 30 degrees
b. In a high-Fowler's position with the left arm extended
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table - Answer ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to collect at
the lung bases, and expands the intercostal space so that access to the pleural space is easier.
The other positions would increase the work of breathing for the patient and make it more
difficult for the health care provider performing the thoracentesis.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm
Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure - Answer ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.
The low pH and low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low
oxygen saturation rate, and a decrease in venous O2 pressure would not be caused by acidosis.
, On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during
inhalation in the lower third of both lungs. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes - Answer ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-
pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory
cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating
sounds that are usually heard during both inspiration and expiration.
A patient with a chronic cough has a bronchoscopy. After the procedure, which intervention by
the nurse is most appropriate?
a. Elevate the head of the bed to 80 to 90 degrees.
b. Keep the patient NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours after bronchoscopy.
d. Notify the health care provider about blood-tinged mucus. - Answer ANS: B
Risk for aspiration and maintaining an open airway is the priority. Because a local anesthetic is
used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the
return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged
mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and
the head of the bed does not need to be in the high-Fowler's position.
The nurse completes a shift assessment on a patient admitted in the early phase of heart
failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration heard on inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration - Answer
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are
continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a
series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are
continuous high-pitched musical sounds on inspiration and expiration.
The nurse observes a student who is listening to a patient's lungs who is having no problems
with breathing. Which action by the student indicates a need to review respiratory assessment
skills?
