304 EXAM 3 Practice Questions with
Correct Answers
What will you do: Patient is short of breath? - ANSWERSRaise HOB, lung sounds,
respiratory rate, O2 saturation. ADMINISTER O2
What will you do: new productive cough? - ANSWERSColor of sputum, consistency?
What will you do: new fine crackles? - ANSWERSDeep breaths, can they clear it with a
cough? Notify physician, o2 stats.
What will you do: Pt. is swallowing meds, they begin to choke. - ANSWERSHeimlich
What will you do: Sputum turned yellowish-green? - ANSWERS
Assessment data: COPD patient, respiratory rate of 35, use of accessory muscles,
while sitting in the chair. O2 sats 95% on 2L NC. Which statement most correctly
reflects the assessment findings?
-The client is hypoxic without signs of respiratory distress.
-The client is apneic and in acute distress.
-The client is dyspneic at rest without assessed hypoxia.
-The client is hypoxic with dyspnea on exertion with exacerbation of COPD. -
ANSWERSThe client is dyspneic at rest without assessed hypoxia.
The nurse is caring for a client with an acute asthma exacerbation. What priority
assessment would concern the nurse most?
1. Shortness of breath and temperature above 100 degrees.
2. An Oxygen saturation of 90% and pulse rate > than 80.
3. Inspiratory wheezing and respiratory rate greater than 30.
4. Tachycardia and pursed-lip breathing. - ANSWERS3. Inspiratory wheezing and
respiratory rate greater than 30.
Rationale: During an acute attack, the person sits forward to maximize the
diaphragmatic movement with prominent wheezing, a respiratory rate higher than 30
breaths/minute, and pulse greater than 120 beats/minute. Accessory muscles in the
neck are straining to lift the chest wall, and the client is often agitated (from hypoxemia).
The nurse has completed the assessment for a client in the clinic with a diagnosis of
chronic asthma. What would be the priority goal the nurse should discuss with the
client?
1. Maintaining a regular exercise routine.
, 2. Complying with medication instructions.
3. Recognizing triggers that cause asthma attacks
4. Understanding physical limitations caused by this disease. - ANSWERS3.
Recognizing triggers that cause asthma attacks
Rationale: The priority goal is asthma control as evidenced by minimal symptoms both
during the day and at night. While medication compliance is important, recognizing
triggers that cause symptoms is the priority to control symptoms
The nurse is assessing a client with a diagnosis of adult respiratory distress syndrome.
What findings will the nurse anticipate?
1. Lethargy, muscle cramping, and shortness of breath.
2. Restlessness, confusion, and agitation
3. Hypotension, diaphoresis, and anxiety.
4. Bradycardia, hyperventilation, and nausea. - ANSWERS2. Restlessness, confusion,
and agitation
Rationale: With acute respiratory distress restlessness, confusion, agitation, and
combative behavior could suggest inadequate O2 delivery to the brain. These
symptoms require immediate action.
The nurse is caring for a client with pulmonary hypertension who asks "Am I going to
die?" What is the best response by the nurse?
1. "Of course you aren't going to die, we are taking good care of you."
2. "Pulmonary hypertension is a scary diagnosis but it won't kill you."
3. "You sound frightened, can you tell me more about that."
4. "We can give you medications to control your symptoms." - ANSWERS3. "You sound
frightened, can you tell me more about that."
Rationale: The treatment of pulmonary hypertension can be challenging, and early
diagnosis can prevent permanent heart damage. Encouraging the client to talk about
fears and anxiety can be helpful but never provide false reassurances that are not
warranted.
The nurse is teaching the client pursed-lip breathing techniques. What guidelines should
the nurse include? Select all that apply.
1. Inhale slowly and deeply through the mouth.
2. Exhalation should be 3 times as long as inhalation.
3. Purse lips like whistling to exhale.
4. Puff cheeks while doing pursed-lip breathing.
5. Use pursed-lip breathing before and after activities. - ANSWERS2. Exhalation should
be 3 times as long as inhalation.
3. Purse lips like whistling to exhale.
Correct Answers
What will you do: Patient is short of breath? - ANSWERSRaise HOB, lung sounds,
respiratory rate, O2 saturation. ADMINISTER O2
What will you do: new productive cough? - ANSWERSColor of sputum, consistency?
What will you do: new fine crackles? - ANSWERSDeep breaths, can they clear it with a
cough? Notify physician, o2 stats.
What will you do: Pt. is swallowing meds, they begin to choke. - ANSWERSHeimlich
What will you do: Sputum turned yellowish-green? - ANSWERS
Assessment data: COPD patient, respiratory rate of 35, use of accessory muscles,
while sitting in the chair. O2 sats 95% on 2L NC. Which statement most correctly
reflects the assessment findings?
-The client is hypoxic without signs of respiratory distress.
-The client is apneic and in acute distress.
-The client is dyspneic at rest without assessed hypoxia.
-The client is hypoxic with dyspnea on exertion with exacerbation of COPD. -
ANSWERSThe client is dyspneic at rest without assessed hypoxia.
The nurse is caring for a client with an acute asthma exacerbation. What priority
assessment would concern the nurse most?
1. Shortness of breath and temperature above 100 degrees.
2. An Oxygen saturation of 90% and pulse rate > than 80.
3. Inspiratory wheezing and respiratory rate greater than 30.
4. Tachycardia and pursed-lip breathing. - ANSWERS3. Inspiratory wheezing and
respiratory rate greater than 30.
Rationale: During an acute attack, the person sits forward to maximize the
diaphragmatic movement with prominent wheezing, a respiratory rate higher than 30
breaths/minute, and pulse greater than 120 beats/minute. Accessory muscles in the
neck are straining to lift the chest wall, and the client is often agitated (from hypoxemia).
The nurse has completed the assessment for a client in the clinic with a diagnosis of
chronic asthma. What would be the priority goal the nurse should discuss with the
client?
1. Maintaining a regular exercise routine.
, 2. Complying with medication instructions.
3. Recognizing triggers that cause asthma attacks
4. Understanding physical limitations caused by this disease. - ANSWERS3.
Recognizing triggers that cause asthma attacks
Rationale: The priority goal is asthma control as evidenced by minimal symptoms both
during the day and at night. While medication compliance is important, recognizing
triggers that cause symptoms is the priority to control symptoms
The nurse is assessing a client with a diagnosis of adult respiratory distress syndrome.
What findings will the nurse anticipate?
1. Lethargy, muscle cramping, and shortness of breath.
2. Restlessness, confusion, and agitation
3. Hypotension, diaphoresis, and anxiety.
4. Bradycardia, hyperventilation, and nausea. - ANSWERS2. Restlessness, confusion,
and agitation
Rationale: With acute respiratory distress restlessness, confusion, agitation, and
combative behavior could suggest inadequate O2 delivery to the brain. These
symptoms require immediate action.
The nurse is caring for a client with pulmonary hypertension who asks "Am I going to
die?" What is the best response by the nurse?
1. "Of course you aren't going to die, we are taking good care of you."
2. "Pulmonary hypertension is a scary diagnosis but it won't kill you."
3. "You sound frightened, can you tell me more about that."
4. "We can give you medications to control your symptoms." - ANSWERS3. "You sound
frightened, can you tell me more about that."
Rationale: The treatment of pulmonary hypertension can be challenging, and early
diagnosis can prevent permanent heart damage. Encouraging the client to talk about
fears and anxiety can be helpful but never provide false reassurances that are not
warranted.
The nurse is teaching the client pursed-lip breathing techniques. What guidelines should
the nurse include? Select all that apply.
1. Inhale slowly and deeply through the mouth.
2. Exhalation should be 3 times as long as inhalation.
3. Purse lips like whistling to exhale.
4. Puff cheeks while doing pursed-lip breathing.
5. Use pursed-lip breathing before and after activities. - ANSWERS2. Exhalation should
be 3 times as long as inhalation.
3. Purse lips like whistling to exhale.
