RESPIRATORY EXAM MED-SURG QUESTIONS AND
ANSWERS LATEST 2024 VERSION VERIFIED
RATIONALE GRADED A+
1. Following assessment of a pa�ent with pneumonia, the nurse iden�fies a nursing diagnosis of
ineffec�ve airway clearance. Which assessment data best supports this diagnosis?
a. Weak, nonproduc�ve cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Res�ng pulse oximetry (SpO2) of 85% - ansANS: A
The weak, nonproduc�ve cough indicates that the pa�ent is unable to clear the airway effec�vely. The
other data would be used to support diagnoses such as impaired gas exchange and ineffec�ve breathing
patern.
1. The clinic nurse is teaching a pa�ent with acute sinusi�s. Which interven�ons should the nurse plan to
include in the teaching session (select all that apply)?
a. Decongestants can be used to relieve swelling.
b. Blowing the nose should be avoided to decrease the nosebleed risk.
c. Taking a hot shower will increase sinus drainage and decrease pain.
d. Saline nasal spray can be made at home and used to wash out secre�ons.
e. You will be more comfortable if you keep your head in an upright posi�on. - ansANS: A, C, D, E
The steam and heat from a shower will help thin secre�ons and improve drainage. Decongestants can be
used to relieve swelling. Pa�ents can use either over-the-counter (OTC) sterile saline solu�ons or home-
prepared saline solu�ons to thin and remove secre�ons. Maintaining an upright posture decreases sinus
pressure and the resul�ng pain. Blowing the nose a�er a hot shower or using the saline spray is
recommended to expel secre�ons.
12. Which ac�on should the nurse take first when a pa�ent develops a nosebleed?
a. Pinch the lower por�on of the nose for 10 minutes.
b. Pack the affected nare �ghtly with an epistaxis balloon.
c. Obtain silver nitrate that will be needed for cauteriza�on.
d. Apply ice compresses over the pa�ent's nose and cheeks. - ansANS: A
, RESPIRATORY EXAM MED-SURG QUESTIONS AND
ANSWERS LATEST 2024 VERSION VERIFIED
RATIONALE GRADED A+
The first nursing ac�on for epistaxis is to apply direct pressure by pinching the nostrils. Applica�on of
cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauteriza�on
and nasal packing are medical interven�ons that may be needed if pressure to the nares does not stop
the bleeding, but these are not the first ac�ons to take for a nosebleed.
15. Which pa�ent in the ear, nose, and throat (ENT) clinic should the nurse assess first?
a. A 23-year-old who is complaining of a sore throat and has a muffled voice
b. A 34-year-old who has a "scratchy throat" and a posi�ve rapid strep an�gen test
c. A 55-year-old who is receiving radia�on for throat cancer and has severe fa�gue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed - ansANS: A
The pa�ent's clinical manifesta�on of a muffled voice suggests a possible peritonsillar abscess that could
lead to an airway obstruc�on requiring rapid assessment and poten�al treatment. The other pa�ents do
not have diagnoses or symptoms that indicate any life-threatening problems.
16. The nurse obtains the following assessment data on an older pa�ent who has influenza. Which
informa�on will be most important for the nurse to communicate to the health care provider?
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache - ansANS: B
The crackles indicate that the pa�ent may be developing pneumonia, a common complica�on of
influenza, which would require aggressive treatment. Myalgia, headache, mild temperature eleva�on,
and sore throat with cough are typical manifesta�ons of influenza and are treated with suppor�ve care
measures such as over-the-counter (OTC) pain relievers and increased fluid intake.
18. The nurse is caring for a hospitalized older pa�ent who has nasal packing in place to treat a
nosebleed. Which assessment finding will require the most immediate ac�on by the nurse?
a. The oxygen satura�on is 89%.
b. The nose appears red and swollen.
ANSWERS LATEST 2024 VERSION VERIFIED
RATIONALE GRADED A+
1. Following assessment of a pa�ent with pneumonia, the nurse iden�fies a nursing diagnosis of
ineffec�ve airway clearance. Which assessment data best supports this diagnosis?
a. Weak, nonproduc�ve cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Res�ng pulse oximetry (SpO2) of 85% - ansANS: A
The weak, nonproduc�ve cough indicates that the pa�ent is unable to clear the airway effec�vely. The
other data would be used to support diagnoses such as impaired gas exchange and ineffec�ve breathing
patern.
1. The clinic nurse is teaching a pa�ent with acute sinusi�s. Which interven�ons should the nurse plan to
include in the teaching session (select all that apply)?
a. Decongestants can be used to relieve swelling.
b. Blowing the nose should be avoided to decrease the nosebleed risk.
c. Taking a hot shower will increase sinus drainage and decrease pain.
d. Saline nasal spray can be made at home and used to wash out secre�ons.
e. You will be more comfortable if you keep your head in an upright posi�on. - ansANS: A, C, D, E
The steam and heat from a shower will help thin secre�ons and improve drainage. Decongestants can be
used to relieve swelling. Pa�ents can use either over-the-counter (OTC) sterile saline solu�ons or home-
prepared saline solu�ons to thin and remove secre�ons. Maintaining an upright posture decreases sinus
pressure and the resul�ng pain. Blowing the nose a�er a hot shower or using the saline spray is
recommended to expel secre�ons.
12. Which ac�on should the nurse take first when a pa�ent develops a nosebleed?
a. Pinch the lower por�on of the nose for 10 minutes.
b. Pack the affected nare �ghtly with an epistaxis balloon.
c. Obtain silver nitrate that will be needed for cauteriza�on.
d. Apply ice compresses over the pa�ent's nose and cheeks. - ansANS: A
, RESPIRATORY EXAM MED-SURG QUESTIONS AND
ANSWERS LATEST 2024 VERSION VERIFIED
RATIONALE GRADED A+
The first nursing ac�on for epistaxis is to apply direct pressure by pinching the nostrils. Applica�on of
cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauteriza�on
and nasal packing are medical interven�ons that may be needed if pressure to the nares does not stop
the bleeding, but these are not the first ac�ons to take for a nosebleed.
15. Which pa�ent in the ear, nose, and throat (ENT) clinic should the nurse assess first?
a. A 23-year-old who is complaining of a sore throat and has a muffled voice
b. A 34-year-old who has a "scratchy throat" and a posi�ve rapid strep an�gen test
c. A 55-year-old who is receiving radia�on for throat cancer and has severe fa�gue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed - ansANS: A
The pa�ent's clinical manifesta�on of a muffled voice suggests a possible peritonsillar abscess that could
lead to an airway obstruc�on requiring rapid assessment and poten�al treatment. The other pa�ents do
not have diagnoses or symptoms that indicate any life-threatening problems.
16. The nurse obtains the following assessment data on an older pa�ent who has influenza. Which
informa�on will be most important for the nurse to communicate to the health care provider?
a. Fever of 100.4° F (38° C)
b. Diffuse crackles in the lungs
c. Sore throat and frequent cough
d. Myalgia and persistent headache - ansANS: B
The crackles indicate that the pa�ent may be developing pneumonia, a common complica�on of
influenza, which would require aggressive treatment. Myalgia, headache, mild temperature eleva�on,
and sore throat with cough are typical manifesta�ons of influenza and are treated with suppor�ve care
measures such as over-the-counter (OTC) pain relievers and increased fluid intake.
18. The nurse is caring for a hospitalized older pa�ent who has nasal packing in place to treat a
nosebleed. Which assessment finding will require the most immediate ac�on by the nurse?
a. The oxygen satura�on is 89%.
b. The nose appears red and swollen.
