MEDSURG -Assessment Of
Respiratory System (25)
2025 Latest
1. 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.
2. The Nurse Prepares A Patient With A Left-Sided Pleural Effusion For A Thoracentesis. How Should The Nurse Position The
Patient?
a. High-Fowler’s Position With The Left Arm Extended
b. Supine With The Head Of The Bed Elevated 30 Degrees
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
3. A Diabetic Patient’s Arterial Blood Gas (ABG) Results Are Ph 7.28; Paco 2 34 Mm Hg; Pao2 85 Mm Hg; HCO3– 18 Meq/L. The Nurse
Would Expect Which Finding?
a. Intercostal Retractions C. Low Oxygen Saturation (Spo2)
b. Kussmaul Respirations D. Decreased Venous O2 Pressure
4. 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
5. The Nurse Palpates The Posterior Chest While The Patient Says “99” And Notes Absent Fremitus. Which Action Should The Nurse
Take Next?
a. Palpate The Anterior Chest And Observe For Barrel Chest.
b. Encourage The Patient To Turn, Cough, And Deep Breathe.
c. Review The Chest X-Ray Report For Evidence Of Pneumonia.
d. Auscultate Anterior And Posterior Breath Sounds Bilaterally.
6. A Patient With A Chronic Cough Is Scheduled To Have A Bronchoscopy With Biopsy. Which Intervention Will The Nurse
Implement Directly After The Procedure?
a. Encourage The Patient To Drink Clear Liquids.
, b. Place The Patient On Bed Rest For At Least 4 Hours.
c. Keep The Patient NPO Until The Gag Reflex Returns.
d. Maintain The Head Of The Bed Elevated 90 Degrees.
7. 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 During Inspiration
d. A Series Of Long-Duration, Discontinuous, Low-Pitched Sounds During Inspiration
8. The Nurse Observes That A Patient With Respiratory Disease Experiences A Decrease In Spo 2 From 93% To 88% While The Patient
Is Ambulating. What Is The Priority Action Of The Nurse? A. Notify The Health Care Provider.
b. Administer PRN Supplemental O2.
c. Document The Response To Exercise.
d. Encourage The Patient To Pace Activity.
9. The Nurse Teaches A Patient About Pulmonary Spirometry Testing. Which Statement, If Made By The Patient, Indicates Teaching
Was Effective?
a. “I Should Use My Inhaler Right Before The Test.”
b. “I Won’t Eat Or Drink Anything 8 Hours Before The Test.”
c. “I Will Inhale Deeply And Blow Out Hard During The Test.”
d. “My Blood Pressure And Pulse Will Be Checked Every 15 Minutes.”
10. The Nurse Observes A Student Who Is Listening To A Patient’s Lungs. Which Action By The Student Indicates A Need To Review
Respiratory Assessment Skills?
a. The Student Compares Breath Sounds From Side To Side At Each Level.
b. The Student Listens During The Inspiratory Phase, Then Moves The Stethoscope.
c. The Student Starts At The Apices Of The Lungs, Moving Down Toward The Lung Bases.
d. The Student Instructs The Patient To Breathe Slowly And Deeply Through The Mouth.
11. A Patient Who Has A History Of Chronic Obstructive Pulmonary Disease (COPD) Was Hospitalized For Increasing Shortness Of
Breath And Chronic Hypoxemia (Sao2 Levels Of 89% To 90%). In Planning For Discharge, Which Action By The Nurse Will Be Most
Effective In Improving Compliance With Discharge Teaching? A. Have The Patient Repeat The Instructions Immediately After
Teaching.
b. Accomplish The Patient Teaching Just Before The Scheduled Discharge.
c. Arrange For The Patient’s Caregiver To Be Present During The Teaching.
d. Start Giving The Patient Discharge Teaching During The Admission Process.
12. A Patient Admitted To The Emergency Department Complaining Of Sudden Onset Shortness Of Breath Is Diagnosed With A
Possible Pulmonary Embolus. How Should The Nurse Prepare The Patient For Diagnostic Testing To Confirm The Diagnosis? A.
Ensure That The Patient Has Been NPO.
b. Start An IV So Contrast Media May Be Given.
c. Inform Radiology That Radioactive Glucose Preparation Is Needed.
d. Instruct The Patient To Expect To Inspire Deeply And Exhale Forcefully.
13. The Nurse Admits A Patient Who Has A Diagnosis Of An Acute Asthma Attack. Which Statement Indicates That The Patient May
Need Teaching Regarding Medication Use?
a. “I Have Not Had Any Acute Asthma Attacks During The Past Year.”
b. “I Became Short Of Breath An Hour Before Coming To The Hospital.”
c. “I’ve Been Taking Tylenol 650 Mg Every 6 Hours For Chest Wall Pain.”
d. “I’ve Been Using My Albuterol Inhaler More Frequently Over The Last 4 Days.”
14. A Patient With Acute Dyspnea Is Scheduled For A Spiral Computed Tomography (CT) Scan. Which Information Obtained By The
Nurse Is A Priority To Communicate To The Health Care Provider Before The CT?
a. Allergy To Shellfish C. Respiratory Rate Of 30
b. Apical Pulse Of 104 D. O2 Saturation Of 90%
15. The Nurse Analyzes The Results Of A Patient’s Arterial Blood Gases (Abgs). Which Finding Would Require Immediate Action?
a. The Bicarbonate Level (HCO3–) Is 31 Meq/L.
b. The Arterial Oxygen Saturation (Sao2) Is 92%.
c. The Partial Pressure Of CO2 In Arterial Blood (Paco2) Is 31 Mm Hg.
d. The Partial Pressure Of Oxygen In Arterial Blood (Pao 2) Is 59 Mm Hg.
,16. Which Assessment Finding Indicates That The Nurse Should Take Immediate Action For An Older Patient?
a. Weak Cough Effort C. Dry Mucous Membranes
b. Barrel-Shaped Chest D. Bilateral Basilar Crackles
17. A Patient In Metabolic Alkalosis Is Admitted To The Emergency Department And Pulse Oximetry (Spo 2) Indicates That The O2
Saturation Is 94%. Which Action Should The Nurse Expect To Take Next? A. Complete A Head-To-Toe Assessment.
b. Administer An Inhaled Bronchodilator.
c. Place The Patient On High-Flow Oxygen.
d. Obtain Repeat Arterial Blood Gases (Abgs).
18. After The Nurse Has Received Change-Of-Shift Report, Which Patient Should The Nurse Assess First?
a. A Patient With Pneumonia Who Has Crackles In The Right Lung Base
b. A Patient With Chronic Bronchitis Who Has A Low Forced Vital Capacity
c. A Patient With Possible Lung Cancer Who Has Just Returned After Bronchoscopy
d. A Patient With Hemoptysis And A 16-Mm Induration After Tuberculin Skin Testing
19. The Laboratory Has Just Called With The Arterial Blood Gas (ABG) Results On Four Patients. Which Result Is Most Important For
The Nurse To Report Immediately To The Health Care Provider?
a. Ph 7.34, Pao2 82 Mm Hg, Paco2 40 Mm Hg, And O2 Sat 97%
b. Ph 7.35, Pao2 85 Mm Hg, Paco2 50 Mm Hg, And O2 Sat 95%
c. Ph 7.46, Pao2 90 Mm Hg, Paco2 32 Mm Hg, And O2 Sat 98%
d. Ph 7.31, Pao2 91 Mm Hg, Paco2 50 Mm Hg, And O2 Sat 96%
20. The Nurse Assesses A Patient With Chronic Obstructive Pulmonary Disease (COPD) Who Has Been Admitted With Increasing
Dyspnea Over The Past 3 Days. Which Finding Is Important For The Nurse To Report To The Health Care Provider? A.
Respirations Are 36 Breaths/Min.
b. Anterior-Posterior Chest Ratio Is 1:1.
c. Lung Expansion Is Decreased Bilaterally.
d. Hyperresonance To Percussion Is Present.
21. Using The Illustrated Technique, The Nurse Is Assessing For Which Finding In A Patient With Chronic Obstructive Pulmonary
Disease (COPD)?
a. HyperresonanceC. Reduced Excursion
b. Tripod Positioning D. Accessory Muscle Use
22. Which Action Is Appropriate For The Nurse To Delegate To Unlicensed Assistive Personnel (UAP)?
a. Listen To A Patient’s Lung Sounds For Wheezes Or Crackles.
b. Label Specimens Obtained During Percutaneous Lung Biopsy.
c. Instruct A Patient About How To Use Home Spirometry Testing.
d. Measure Induration At The Site Of A Patient’s Intradermal Skin Test.
1. A Patient Is Scheduled For A Computed Tomography (CT) Scan Of The Chest With Contrast Media. Which Assessment Findings
Should The Nurse Report To The Health Care Provider Before The Patient Goes For The CT (Select All That Apply)? A. Allergy
To Shellfish
b. Patient Reports Claustrophobia
c. Elevated Serum Creatinine Level
d. Recent Bronchodilator Inhaler Use
e. Inability To Remove A Wedding Band
Upper Respiratory Problems (26)
1. The Nurse Teaches A Patient About Discharge Instructions After A Rhinoplasty. Which Statement, If Made By The Patient,
Indicates That The Teaching Was Successful?
a. “My Nose Will Look Normal After 24 To 48 Hours.”
b. “I Can Take 800 Mg Ibuprofen Every 6 Hours For Pain.”
c. “I Will Remove And Reapply The Nasal Packing Every Day.”
d. “I Will Elevate My Head For 48 Hours To Minimize Swelling.”
, 2. The Nurse Plans To Teach A Patient How To Manage Allergic Rhinitis. Which Information Should The Nurse Include In The
Teaching Plan?
a. Using Oral Antihistamines For 2 Weeks Before The Allergy Season May Prevent Reactions.
b. Identifying And Avoiding Environmental Triggers Are The Best Way To Prevent Symptoms.
c. Frequent Hand Washing Is The Primary Way To Prevent Spreading The Condition To Others.
d. Corticosteroid Nasal Sprays Will Reduce Inflammation, But Systemic Effects Limit Their Use.
3. The Nurse Discusses Management Of Upper Respiratory Infections (Uris) With A Patient Who Has Acute Sinusitis. Which
Statement By The Patient Indicates That Additional Teaching Is Needed? A. “I Will Drink Lots Of Juices And Other Fluids
To Stay Well Hydrated.”
b. “I Can Use Nasal Decongestant Spray Until The Congestion Is Gone.”
c. “I Can Take Acetaminophen (Tylenol) To Treat My Sinus Discomfort.”
d. “I Will Watch For Changes In Nasal Secretions Or The Sputum That I Cough Up.”
4. The Nurse Has Just Auscultated Coarse Crackles Bilaterally On A Patient With A Tracheostomy Tube In Place. If The Patient Is
Unsuccessful In Coughing Up Secretions, What Action Should The Nurse Take? A. Encourage Increased Incentive Spirometer
Use.
b. Encourage The Patient To Increase Oral Fluid Intake.
c. Put On Sterile Gloves And Use A Sterile Catheter To Suction.
d. Preoxygenate The Patient For 3 Minutes Before Suctioning.
5. A Patient With A Tracheostomy Has A New Order For A Fenestrated Tracheostomy Tube. Which Action Should The Nurse Include
In The Plan Of Care In Collaboration With The Speech Therapist? A. Leave The Tracheostomy Inner Cannula Inserted At All
Times.
b. Place The Decannulation Cap In The Tube Before Cuff Deflation.
c. Assess The Ability To Swallow Before Using The Fenestrated Tube.
d. Inflate The Tracheostomy Cuff During Use Of The Fenestrated Tube.
6. The Nurse Is Caring For A Mechanically Ventilated Patient With A Cuffed Tracheostomy Tube. Which Action By The Nurse Would
Determine If The Cuff Has Been Properly Inflated?
a. Use A Hand-Held Manometer To Measure Cuff Pressure.
b. Review The Health Record For The Prescribed Cuff Pressure.
c. Suction The Patient Through A Fenestrated Inner Cannula To Clear Secretions.
d. Insert The Decannulation Plug Before Removing The Nonfenestrated Inner Cannula.
7. Which Statement By The Patient Indicates That Teaching Has Been Effective For A Patient Scheduled For Radiation Therapy Of
The Larynx?
a. “I Will Need To Buy A Water Bottle To Carry With Me.”
b. “I Should Not Use Any Lotions On My Neck And Throat.”
c. “Until The Radiation Is Complete, I May Have Diarrhea.”
d. “Alcohol-Based Mouthwashes Will Help Clean My Mouth.”
8. A Nurse Obtains A Health History From A Patient Who Has A 35 Pack-Year Smoking History. The Patient Complains Of Hoarseness
And Tightness In The Throat And Difficulty Swallowing. Which Question Is Important For The Nurse To Ask? A. “How
Much Alcohol Do You Drink In An Average Week?”
b. “Do You Have A Family History Of Head Or Neck Cancer?”
c. “Have You Had Frequent Streptococcal Throat Infections?”
d. “Do You Use Antihistamines For Upper Airway Congestion?”
9. A Patient Scheduled For A Total Laryngectomy And Radical Neck Dissection For Cancer Of The Larynx Asks The Nurse, “Will I Be
Able To Talk Normally After Surgery?” What Is The Most Accurate Response By The Nurse?
a. “You Will Breathe Through A Permanent Opening In Your Neck, But You Will Not Be Able To Communicate Orally.”
b. “You Won’t Be Able To Talk Right After Surgery, But You Will Be Able To Speak Again After The Tracheostomy Tube Is
Removed.”
c. “You Will Have A Permanent Opening Into Your Neck, And You Will Need Rehabilitation For Some Type Of Voice
Restoration.”
d. “You Won’t Be Able To Speak As You Used To, But There Are Artificial Voice Devices That Will Give You The Ability To Speak
Normally.”
10. A Patient Who Had A Total Laryngectomy Has A Nursing Diagnosis Of Hopelessness Related To Loss Of Control Of Personal Care.
Which Information Obtained By The Nurse Indicates That This Identified Problem Is Resolving? A. The Patient Allows The
Nurse To Suction The Tracheostomy.
Respiratory System (25)
2025 Latest
1. 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.
2. The Nurse Prepares A Patient With A Left-Sided Pleural Effusion For A Thoracentesis. How Should The Nurse Position The
Patient?
a. High-Fowler’s Position With The Left Arm Extended
b. Supine With The Head Of The Bed Elevated 30 Degrees
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
3. A Diabetic Patient’s Arterial Blood Gas (ABG) Results Are Ph 7.28; Paco 2 34 Mm Hg; Pao2 85 Mm Hg; HCO3– 18 Meq/L. The Nurse
Would Expect Which Finding?
a. Intercostal Retractions C. Low Oxygen Saturation (Spo2)
b. Kussmaul Respirations D. Decreased Venous O2 Pressure
4. 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
5. The Nurse Palpates The Posterior Chest While The Patient Says “99” And Notes Absent Fremitus. Which Action Should The Nurse
Take Next?
a. Palpate The Anterior Chest And Observe For Barrel Chest.
b. Encourage The Patient To Turn, Cough, And Deep Breathe.
c. Review The Chest X-Ray Report For Evidence Of Pneumonia.
d. Auscultate Anterior And Posterior Breath Sounds Bilaterally.
6. A Patient With A Chronic Cough Is Scheduled To Have A Bronchoscopy With Biopsy. Which Intervention Will The Nurse
Implement Directly After The Procedure?
a. Encourage The Patient To Drink Clear Liquids.
, b. Place The Patient On Bed Rest For At Least 4 Hours.
c. Keep The Patient NPO Until The Gag Reflex Returns.
d. Maintain The Head Of The Bed Elevated 90 Degrees.
7. 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 During Inspiration
d. A Series Of Long-Duration, Discontinuous, Low-Pitched Sounds During Inspiration
8. The Nurse Observes That A Patient With Respiratory Disease Experiences A Decrease In Spo 2 From 93% To 88% While The Patient
Is Ambulating. What Is The Priority Action Of The Nurse? A. Notify The Health Care Provider.
b. Administer PRN Supplemental O2.
c. Document The Response To Exercise.
d. Encourage The Patient To Pace Activity.
9. The Nurse Teaches A Patient About Pulmonary Spirometry Testing. Which Statement, If Made By The Patient, Indicates Teaching
Was Effective?
a. “I Should Use My Inhaler Right Before The Test.”
b. “I Won’t Eat Or Drink Anything 8 Hours Before The Test.”
c. “I Will Inhale Deeply And Blow Out Hard During The Test.”
d. “My Blood Pressure And Pulse Will Be Checked Every 15 Minutes.”
10. The Nurse Observes A Student Who Is Listening To A Patient’s Lungs. Which Action By The Student Indicates A Need To Review
Respiratory Assessment Skills?
a. The Student Compares Breath Sounds From Side To Side At Each Level.
b. The Student Listens During The Inspiratory Phase, Then Moves The Stethoscope.
c. The Student Starts At The Apices Of The Lungs, Moving Down Toward The Lung Bases.
d. The Student Instructs The Patient To Breathe Slowly And Deeply Through The Mouth.
11. A Patient Who Has A History Of Chronic Obstructive Pulmonary Disease (COPD) Was Hospitalized For Increasing Shortness Of
Breath And Chronic Hypoxemia (Sao2 Levels Of 89% To 90%). In Planning For Discharge, Which Action By The Nurse Will Be Most
Effective In Improving Compliance With Discharge Teaching? A. Have The Patient Repeat The Instructions Immediately After
Teaching.
b. Accomplish The Patient Teaching Just Before The Scheduled Discharge.
c. Arrange For The Patient’s Caregiver To Be Present During The Teaching.
d. Start Giving The Patient Discharge Teaching During The Admission Process.
12. A Patient Admitted To The Emergency Department Complaining Of Sudden Onset Shortness Of Breath Is Diagnosed With A
Possible Pulmonary Embolus. How Should The Nurse Prepare The Patient For Diagnostic Testing To Confirm The Diagnosis? A.
Ensure That The Patient Has Been NPO.
b. Start An IV So Contrast Media May Be Given.
c. Inform Radiology That Radioactive Glucose Preparation Is Needed.
d. Instruct The Patient To Expect To Inspire Deeply And Exhale Forcefully.
13. The Nurse Admits A Patient Who Has A Diagnosis Of An Acute Asthma Attack. Which Statement Indicates That The Patient May
Need Teaching Regarding Medication Use?
a. “I Have Not Had Any Acute Asthma Attacks During The Past Year.”
b. “I Became Short Of Breath An Hour Before Coming To The Hospital.”
c. “I’ve Been Taking Tylenol 650 Mg Every 6 Hours For Chest Wall Pain.”
d. “I’ve Been Using My Albuterol Inhaler More Frequently Over The Last 4 Days.”
14. A Patient With Acute Dyspnea Is Scheduled For A Spiral Computed Tomography (CT) Scan. Which Information Obtained By The
Nurse Is A Priority To Communicate To The Health Care Provider Before The CT?
a. Allergy To Shellfish C. Respiratory Rate Of 30
b. Apical Pulse Of 104 D. O2 Saturation Of 90%
15. The Nurse Analyzes The Results Of A Patient’s Arterial Blood Gases (Abgs). Which Finding Would Require Immediate Action?
a. The Bicarbonate Level (HCO3–) Is 31 Meq/L.
b. The Arterial Oxygen Saturation (Sao2) Is 92%.
c. The Partial Pressure Of CO2 In Arterial Blood (Paco2) Is 31 Mm Hg.
d. The Partial Pressure Of Oxygen In Arterial Blood (Pao 2) Is 59 Mm Hg.
,16. Which Assessment Finding Indicates That The Nurse Should Take Immediate Action For An Older Patient?
a. Weak Cough Effort C. Dry Mucous Membranes
b. Barrel-Shaped Chest D. Bilateral Basilar Crackles
17. A Patient In Metabolic Alkalosis Is Admitted To The Emergency Department And Pulse Oximetry (Spo 2) Indicates That The O2
Saturation Is 94%. Which Action Should The Nurse Expect To Take Next? A. Complete A Head-To-Toe Assessment.
b. Administer An Inhaled Bronchodilator.
c. Place The Patient On High-Flow Oxygen.
d. Obtain Repeat Arterial Blood Gases (Abgs).
18. After The Nurse Has Received Change-Of-Shift Report, Which Patient Should The Nurse Assess First?
a. A Patient With Pneumonia Who Has Crackles In The Right Lung Base
b. A Patient With Chronic Bronchitis Who Has A Low Forced Vital Capacity
c. A Patient With Possible Lung Cancer Who Has Just Returned After Bronchoscopy
d. A Patient With Hemoptysis And A 16-Mm Induration After Tuberculin Skin Testing
19. The Laboratory Has Just Called With The Arterial Blood Gas (ABG) Results On Four Patients. Which Result Is Most Important For
The Nurse To Report Immediately To The Health Care Provider?
a. Ph 7.34, Pao2 82 Mm Hg, Paco2 40 Mm Hg, And O2 Sat 97%
b. Ph 7.35, Pao2 85 Mm Hg, Paco2 50 Mm Hg, And O2 Sat 95%
c. Ph 7.46, Pao2 90 Mm Hg, Paco2 32 Mm Hg, And O2 Sat 98%
d. Ph 7.31, Pao2 91 Mm Hg, Paco2 50 Mm Hg, And O2 Sat 96%
20. The Nurse Assesses A Patient With Chronic Obstructive Pulmonary Disease (COPD) Who Has Been Admitted With Increasing
Dyspnea Over The Past 3 Days. Which Finding Is Important For The Nurse To Report To The Health Care Provider? A.
Respirations Are 36 Breaths/Min.
b. Anterior-Posterior Chest Ratio Is 1:1.
c. Lung Expansion Is Decreased Bilaterally.
d. Hyperresonance To Percussion Is Present.
21. Using The Illustrated Technique, The Nurse Is Assessing For Which Finding In A Patient With Chronic Obstructive Pulmonary
Disease (COPD)?
a. HyperresonanceC. Reduced Excursion
b. Tripod Positioning D. Accessory Muscle Use
22. Which Action Is Appropriate For The Nurse To Delegate To Unlicensed Assistive Personnel (UAP)?
a. Listen To A Patient’s Lung Sounds For Wheezes Or Crackles.
b. Label Specimens Obtained During Percutaneous Lung Biopsy.
c. Instruct A Patient About How To Use Home Spirometry Testing.
d. Measure Induration At The Site Of A Patient’s Intradermal Skin Test.
1. A Patient Is Scheduled For A Computed Tomography (CT) Scan Of The Chest With Contrast Media. Which Assessment Findings
Should The Nurse Report To The Health Care Provider Before The Patient Goes For The CT (Select All That Apply)? A. Allergy
To Shellfish
b. Patient Reports Claustrophobia
c. Elevated Serum Creatinine Level
d. Recent Bronchodilator Inhaler Use
e. Inability To Remove A Wedding Band
Upper Respiratory Problems (26)
1. The Nurse Teaches A Patient About Discharge Instructions After A Rhinoplasty. Which Statement, If Made By The Patient,
Indicates That The Teaching Was Successful?
a. “My Nose Will Look Normal After 24 To 48 Hours.”
b. “I Can Take 800 Mg Ibuprofen Every 6 Hours For Pain.”
c. “I Will Remove And Reapply The Nasal Packing Every Day.”
d. “I Will Elevate My Head For 48 Hours To Minimize Swelling.”
, 2. The Nurse Plans To Teach A Patient How To Manage Allergic Rhinitis. Which Information Should The Nurse Include In The
Teaching Plan?
a. Using Oral Antihistamines For 2 Weeks Before The Allergy Season May Prevent Reactions.
b. Identifying And Avoiding Environmental Triggers Are The Best Way To Prevent Symptoms.
c. Frequent Hand Washing Is The Primary Way To Prevent Spreading The Condition To Others.
d. Corticosteroid Nasal Sprays Will Reduce Inflammation, But Systemic Effects Limit Their Use.
3. The Nurse Discusses Management Of Upper Respiratory Infections (Uris) With A Patient Who Has Acute Sinusitis. Which
Statement By The Patient Indicates That Additional Teaching Is Needed? A. “I Will Drink Lots Of Juices And Other Fluids
To Stay Well Hydrated.”
b. “I Can Use Nasal Decongestant Spray Until The Congestion Is Gone.”
c. “I Can Take Acetaminophen (Tylenol) To Treat My Sinus Discomfort.”
d. “I Will Watch For Changes In Nasal Secretions Or The Sputum That I Cough Up.”
4. The Nurse Has Just Auscultated Coarse Crackles Bilaterally On A Patient With A Tracheostomy Tube In Place. If The Patient Is
Unsuccessful In Coughing Up Secretions, What Action Should The Nurse Take? A. Encourage Increased Incentive Spirometer
Use.
b. Encourage The Patient To Increase Oral Fluid Intake.
c. Put On Sterile Gloves And Use A Sterile Catheter To Suction.
d. Preoxygenate The Patient For 3 Minutes Before Suctioning.
5. A Patient With A Tracheostomy Has A New Order For A Fenestrated Tracheostomy Tube. Which Action Should The Nurse Include
In The Plan Of Care In Collaboration With The Speech Therapist? A. Leave The Tracheostomy Inner Cannula Inserted At All
Times.
b. Place The Decannulation Cap In The Tube Before Cuff Deflation.
c. Assess The Ability To Swallow Before Using The Fenestrated Tube.
d. Inflate The Tracheostomy Cuff During Use Of The Fenestrated Tube.
6. The Nurse Is Caring For A Mechanically Ventilated Patient With A Cuffed Tracheostomy Tube. Which Action By The Nurse Would
Determine If The Cuff Has Been Properly Inflated?
a. Use A Hand-Held Manometer To Measure Cuff Pressure.
b. Review The Health Record For The Prescribed Cuff Pressure.
c. Suction The Patient Through A Fenestrated Inner Cannula To Clear Secretions.
d. Insert The Decannulation Plug Before Removing The Nonfenestrated Inner Cannula.
7. Which Statement By The Patient Indicates That Teaching Has Been Effective For A Patient Scheduled For Radiation Therapy Of
The Larynx?
a. “I Will Need To Buy A Water Bottle To Carry With Me.”
b. “I Should Not Use Any Lotions On My Neck And Throat.”
c. “Until The Radiation Is Complete, I May Have Diarrhea.”
d. “Alcohol-Based Mouthwashes Will Help Clean My Mouth.”
8. A Nurse Obtains A Health History From A Patient Who Has A 35 Pack-Year Smoking History. The Patient Complains Of Hoarseness
And Tightness In The Throat And Difficulty Swallowing. Which Question Is Important For The Nurse To Ask? A. “How
Much Alcohol Do You Drink In An Average Week?”
b. “Do You Have A Family History Of Head Or Neck Cancer?”
c. “Have You Had Frequent Streptococcal Throat Infections?”
d. “Do You Use Antihistamines For Upper Airway Congestion?”
9. A Patient Scheduled For A Total Laryngectomy And Radical Neck Dissection For Cancer Of The Larynx Asks The Nurse, “Will I Be
Able To Talk Normally After Surgery?” What Is The Most Accurate Response By The Nurse?
a. “You Will Breathe Through A Permanent Opening In Your Neck, But You Will Not Be Able To Communicate Orally.”
b. “You Won’t Be Able To Talk Right After Surgery, But You Will Be Able To Speak Again After The Tracheostomy Tube Is
Removed.”
c. “You Will Have A Permanent Opening Into Your Neck, And You Will Need Rehabilitation For Some Type Of Voice
Restoration.”
d. “You Won’t Be Able To Speak As You Used To, But There Are Artificial Voice Devices That Will Give You The Ability To Speak
Normally.”
10. A Patient Who Had A Total Laryngectomy Has A Nursing Diagnosis Of Hopelessness Related To Loss Of Control Of Personal Care.
Which Information Obtained By The Nurse Indicates That This Identified Problem Is Resolving? A. The Patient Allows The
Nurse To Suction The Tracheostomy.
