Saunders Respiratory NCLEX
questions And Answers
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The
nurse determines that the client's respiratory status is worsening based upon which finding?
A. Loud wheezing
B. Wheezing on expiration
C. Noticeably diminished breath sounds
D. Increased displays of emotional apprehension - verified answer C
Noticeably diminished breath sounds are an indication of severe obstruction and impending
respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma
attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks
may not wheeze. The client with severe asthma attacks may have no audible wheezing because of
the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to
produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress
being experienced
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD)
who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per
minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
A. Determine the need to increase the oxygen.
B. Reassure the client that there is no need to worry.
C. Conduct further assessment of the client's respiratory status.
D. Call emergency services to take the client to the emergency department. - verified answer C.
With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further
assessment. Oxygen is not increased without the approval of the primary health care provider,
especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is
"no need to worry" is inappropriate. Calling emergency services is a premature action
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to
do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action?
, A. Breathes in and then holds the breath for 30 seconds
B. Loosens the abdominal muscles while breathing out
C. Inhales with puckered lips and exhales with the mouth open wide
D. Breathes so that expiration is two to three times as long as inspiration - verified answer D.
COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air
trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in
and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD.
Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips
(not with the mouth wide open) increases the intraluminal pressure and prevents the airways from
collapsing.
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a
diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure,
which priority activity should the nurse plan time for after the arterial blood is drawn?
A. Holding a warm compress over the puncture site for 5 minutes
B. Encouraging the client to open and close the hand rapidly for 2 minutes
C. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes
D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes -
verified answer C.
Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma
formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm
compress would increase blood flow. Keeping the extremity still and out of a dependent position will
aid in the formation of a clot at the puncture site
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive
pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see
that the oxygen flow rate is prescribed at which rate?
A. 2 to 3 liters per minute
B. 4 to 5 liters per minute
C. 6 to 8 liters per minute
D. 8 to 10 liters per minute - verified answer A
questions And Answers
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The
nurse determines that the client's respiratory status is worsening based upon which finding?
A. Loud wheezing
B. Wheezing on expiration
C. Noticeably diminished breath sounds
D. Increased displays of emotional apprehension - verified answer C
Noticeably diminished breath sounds are an indication of severe obstruction and impending
respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma
attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks
may not wheeze. The client with severe asthma attacks may have no audible wheezing because of
the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to
produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress
being experienced
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD)
who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per
minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take?
A. Determine the need to increase the oxygen.
B. Reassure the client that there is no need to worry.
C. Conduct further assessment of the client's respiratory status.
D. Call emergency services to take the client to the emergency department. - verified answer C.
With the client's respiratory rate at 22 breaths per minute, the nurse should obtain further
assessment. Oxygen is not increased without the approval of the primary health care provider,
especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is
"no need to worry" is inappropriate. Calling emergency services is a premature action
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to
do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action?
, A. Breathes in and then holds the breath for 30 seconds
B. Loosens the abdominal muscles while breathing out
C. Inhales with puckered lips and exhales with the mouth open wide
D. Breathes so that expiration is two to three times as long as inspiration - verified answer D.
COPD is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air
trapping caused by airway narrowing that occurs in COPD. The client is not instructed to breathe in
and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD.
Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips
(not with the mouth wide open) increases the intraluminal pressure and prevents the airways from
collapsing.
The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a
diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure,
which priority activity should the nurse plan time for after the arterial blood is drawn?
A. Holding a warm compress over the puncture site for 5 minutes
B. Encouraging the client to open and close the hand rapidly for 2 minutes
C. Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes
D. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes -
verified answer C.
Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma
formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm
compress would increase blood flow. Keeping the extremity still and out of a dependent position will
aid in the formation of a clot at the puncture site
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive
pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see
that the oxygen flow rate is prescribed at which rate?
A. 2 to 3 liters per minute
B. 4 to 5 liters per minute
C. 6 to 8 liters per minute
D. 8 to 10 liters per minute - verified answer A
