NUR 211 Exam 3 – Comprehensive Questions and
Answers with Detailed Rationales
1.
A nurse assesses a client who suddenly develops severe shortness of breath,
tachycardia, and anxiety. What is the nurse's priority action?
A. Obtain a complete medication history
B. Assess airway and breathing
C. Encourage oral fluids
D. Place the client in a supine position
Answer: B. Assess airway and breathing
Rationale: Airway and breathing take priority when a client develops acute
respiratory distress. Immediate assessment of oxygenation and ventilation allows
the nurse to identify and address a potentially life-threatening problem.
2.
Which finding is an early manifestation of hypoxia?
A. Restlessness
B. Bradycardia
C. Cyanosis
D. Severe hypotension
Answer: A. Restlessness
Rationale: Restlessness, anxiety, and changes in behavior can occur early when
the brain receives inadequate oxygen. Cyanosis is generally a later and less
sensitive indicator of hypoxemia.
3.
,A client receiving oxygen becomes increasingly confused. What should the nurse
do first?
A. Document the finding
B. Assess oxygenation and respiratory status
C. Offer food
D. Encourage ambulation
Answer: B. Assess oxygenation and respiratory status
Rationale: New confusion may indicate inadequate oxygenation. The nurse
should immediately assess respiratory status, oxygen saturation, airway,
breathing pattern, and other indicators of deterioration.
4.
Which position is generally most helpful for a client experiencing acute dyspnea?
A. Supine
B. Prone
C. Upright
D. Trendelenburg
Answer: C. Upright
Rationale: An upright position can improve lung expansion and decrease the work
of breathing. Supine and Trendelenburg positions can worsen respiratory
difficulty in many dyspneic clients.
5.
A postoperative client is reluctant to cough because of incisional pain. Which
intervention should the nurse use?
A. Tell the client not to cough
B. Encourage shallow breathing only
C. Teach the client to splint the incision
D. Restrict fluids
,Answer: C. Teach the client to splint the incision
Rationale: Supporting the incision with a pillow or the hands can reduce
discomfort during coughing. Effective coughing helps clear secretions and reduce
pulmonary complications.
6.
Which intervention best promotes prevention of postoperative atelectasis?
A. Prolonged bed rest
B. Incentive spirometry and mobility
C. Fluid restriction
D. Avoidance of coughing
Answer: B. Incentive spirometry and mobility
Rationale: Deep breathing, incentive spirometry, repositioning, and early mobility
promote lung expansion and help prevent atelectasis.
7.
Which finding is most concerning in a client with respiratory disease?
A. Respiratory rate of 18/min
B. Mild nasal congestion
C. Inability to speak in complete sentences because of dyspnea
D. Occasional cough
Answer: C. Inability to speak in complete sentences because of dyspnea
Rationale: Inability to speak normally because of respiratory distress suggests
significant impairment of ventilation and requires immediate assessment and
intervention.
8.
, A client has thick respiratory secretions. Which intervention may help loosen
secretions if not contraindicated?
A. Encourage appropriate fluid intake
B. Restrict fluids
C. Keep the client flat
D. Discourage coughing
Answer: A. Encourage appropriate fluid intake
Rationale: Adequate hydration can reduce secretion viscosity and facilitate
expectoration when the client does not have a contraindication to increased
fluids.
9.
Which finding indicates increased work of breathing?
A. Use of accessory muscles
B. Regular respiratory pattern
C. Relaxed facial expression
D. Respiratory rate of 14/min without symptoms
Answer: A. Use of accessory muscles
Rationale: Use of neck, chest, or abdominal accessory muscles indicates increased
effort required to breathe.
10.
A nurse is caring for a client receiving oxygen. Which safety measure is essential?
A. Apply petroleum products around the oxygen equipment
B. Permit smoking if oxygen is temporarily disconnected
C. Keep oxygen away from flames and ignition sources
D. Store oxygen beside a heat source
Answer: C. Keep oxygen away from flames and ignition sources
Answers with Detailed Rationales
1.
A nurse assesses a client who suddenly develops severe shortness of breath,
tachycardia, and anxiety. What is the nurse's priority action?
A. Obtain a complete medication history
B. Assess airway and breathing
C. Encourage oral fluids
D. Place the client in a supine position
Answer: B. Assess airway and breathing
Rationale: Airway and breathing take priority when a client develops acute
respiratory distress. Immediate assessment of oxygenation and ventilation allows
the nurse to identify and address a potentially life-threatening problem.
2.
Which finding is an early manifestation of hypoxia?
A. Restlessness
B. Bradycardia
C. Cyanosis
D. Severe hypotension
Answer: A. Restlessness
Rationale: Restlessness, anxiety, and changes in behavior can occur early when
the brain receives inadequate oxygen. Cyanosis is generally a later and less
sensitive indicator of hypoxemia.
3.
,A client receiving oxygen becomes increasingly confused. What should the nurse
do first?
A. Document the finding
B. Assess oxygenation and respiratory status
C. Offer food
D. Encourage ambulation
Answer: B. Assess oxygenation and respiratory status
Rationale: New confusion may indicate inadequate oxygenation. The nurse
should immediately assess respiratory status, oxygen saturation, airway,
breathing pattern, and other indicators of deterioration.
4.
Which position is generally most helpful for a client experiencing acute dyspnea?
A. Supine
B. Prone
C. Upright
D. Trendelenburg
Answer: C. Upright
Rationale: An upright position can improve lung expansion and decrease the work
of breathing. Supine and Trendelenburg positions can worsen respiratory
difficulty in many dyspneic clients.
5.
A postoperative client is reluctant to cough because of incisional pain. Which
intervention should the nurse use?
A. Tell the client not to cough
B. Encourage shallow breathing only
C. Teach the client to splint the incision
D. Restrict fluids
,Answer: C. Teach the client to splint the incision
Rationale: Supporting the incision with a pillow or the hands can reduce
discomfort during coughing. Effective coughing helps clear secretions and reduce
pulmonary complications.
6.
Which intervention best promotes prevention of postoperative atelectasis?
A. Prolonged bed rest
B. Incentive spirometry and mobility
C. Fluid restriction
D. Avoidance of coughing
Answer: B. Incentive spirometry and mobility
Rationale: Deep breathing, incentive spirometry, repositioning, and early mobility
promote lung expansion and help prevent atelectasis.
7.
Which finding is most concerning in a client with respiratory disease?
A. Respiratory rate of 18/min
B. Mild nasal congestion
C. Inability to speak in complete sentences because of dyspnea
D. Occasional cough
Answer: C. Inability to speak in complete sentences because of dyspnea
Rationale: Inability to speak normally because of respiratory distress suggests
significant impairment of ventilation and requires immediate assessment and
intervention.
8.
, A client has thick respiratory secretions. Which intervention may help loosen
secretions if not contraindicated?
A. Encourage appropriate fluid intake
B. Restrict fluids
C. Keep the client flat
D. Discourage coughing
Answer: A. Encourage appropriate fluid intake
Rationale: Adequate hydration can reduce secretion viscosity and facilitate
expectoration when the client does not have a contraindication to increased
fluids.
9.
Which finding indicates increased work of breathing?
A. Use of accessory muscles
B. Regular respiratory pattern
C. Relaxed facial expression
D. Respiratory rate of 14/min without symptoms
Answer: A. Use of accessory muscles
Rationale: Use of neck, chest, or abdominal accessory muscles indicates increased
effort required to breathe.
10.
A nurse is caring for a client receiving oxygen. Which safety measure is essential?
A. Apply petroleum products around the oxygen equipment
B. Permit smoking if oxygen is temporarily disconnected
C. Keep oxygen away from flames and ignition sources
D. Store oxygen beside a heat source
Answer: C. Keep oxygen away from flames and ignition sources
