NUR254 EXAM 4 (NEW VERSION 2026/2027)
RESPIRATORY GASTROINTESTINAL DISORDER
METHODOLOGY ACCLAMATION CONSTRUCT 2026.
TOP SCORE A+
SECTION I: RESPIRATORY ASSESSMENT & DIAGNOSTIC TESTING (Questions 1–
25)
1. A nurse is performing a respiratory assessment on a 72-year-old client. Which
of the following findings should the nurse identify as an expected age-related
change?
A. Increased vital capacity
B. Decreased residual volume
C. Decreased chest wall compliance
D. Increased cough reflex
Correct Answer: C
Rationale: Age-related changes in the respiratory system include
decreased chest wall compliance due to calcification of costal cartilages,
weakening of respiratory muscles, and decreased elastic recoil of the lungs. Vital
capacity decreases, residual volume increases, and cough reflex is diminished.
These changes increase the older adult's risk for respiratory infections and
impaired gas exchange.
2. A nurse is assessing a client who reports shortness of breath. Which of the
following questions should the nurse ask first?
A. "When did your shortness of breath begin?"
B. "Do you have any chest pain?"
C. "What medications are you currently taking?"
D. "Have you been exposed to anyone who is sick?"
, Correct Answer: A
Rationale: The priority assessment for a client with dyspnea is to
determine the onset, duration, and pattern of the symptom. Understanding when
the shortness of breath began helps the nurse identify whether this is an acute
emergency (e.g., pulmonary embolism, pneumothorax) or a chronic condition
exacerbation. The other questions are important but secondary to establishing
the timeline of the chief complaint.
3. A nurse is auscultating breath sounds and hears a continuous, musical, high-
pitched sound on expiration. The nurse should document this finding as:
A. Crackles
B. Wheezing
C. Pleural friction rub
D. Rhonchi
Correct Answer: B
Rationale: Wheezing is a continuous, musical, high-pitched sound heard
primarily on expiration and is caused by narrowed airways. It is commonly
associated with asthma, COPD, and bronchospasm. Crackles are discontinuous,
brief sounds heard on inspiration; pleural friction rub is a grating sound heard on
both inspiration and expiration; rhonchi are low-pitched, continuous sounds
caused by secretions in large airways.
4. A nurse is preparing a client for an arterial blood gas (ABG) draw. Which of the
following sites is most commonly used for this procedure?
A. Femoral artery
B. Radial artery
C. Brachial artery
D. Dorsalis pedis artery
Correct Answer: B
, Rationale: The radial artery is the most common site for ABG sampling
because it is superficial, easily accessible, and has collateral circulation via the
ulnar artery. Before the procedure, the nurse should perform the modified Allen
test to verify adequate collateral circulation. The femoral artery is used when
radial access is unavailable but carries higher risk of infection and hematoma.
5. A nurse is reviewing ABG results for a client: pH 7.28, PaCO₂ 58 mm Hg, HCO₃⁻
24 mEq/L. The nurse should interpret these results as:
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO₂ above 45 mm Hg
indicates respiratory acidosis because CO₂ is retained. The normal HCO₃⁻ (22–26
mEq/L) indicates no metabolic compensation has occurred yet, making this
uncompensated respiratory acidosis. Common causes include hypoventilation,
COPD exacerbation, and sedative overdose.
6. A nurse is interpreting an ABG result: pH 7.48, PaCO₂ 30 mm Hg, HCO₃⁻ 22
mEq/L. Which of the following conditions is most consistent with these findings?
A. Opioid overdose
B. Hyperventilation
C. Chronic kidney disease
D. Severe diarrhea
Correct Answer: B
Rationale: The elevated pH (alkalosis) and low PaCO₂ indicate respiratory
alkalosis, which is caused by hyperventilation (blowing off CO₂). This can occur
with anxiety, pain, fever, early sepsis, or pulmonary embolism. Opioid overdose
, causes respiratory acidosis; kidney disease causes metabolic acidosis; severe
diarrhea causes metabolic acidosis.
7. A nurse is preparing to perform a tuberculin skin test (Mantoux test). Which of
the following actions should the nurse take?
A. Inject 0.1 mL of purified protein derivative intradermally
B. Inject 0.5 mL of purified protein derivative subcutaneously
C. Administer the injection into the deltoid muscle
D. Use a 25-gauge needle at a 45-degree angle
Correct Answer: A
Rationale: The Mantoux test involves intradermal injection of 0.1 mL of
purified protein derivative (PPD) into the inner forearm, creating a wheal. A 27-
gauge needle at a 5- to 15-degree angle is used. Subcutaneous or intramuscular
administration is incorrect. The test is read 48–72 hours after administration by
measuring induration (not redness).
8. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the
following instructions should the nurse include in the pre-procedure teaching?
A. "You will need to lie flat for 6 hours after the procedure."
B. "You should not eat or drink anything after midnight."
C. "You will be able to drive yourself home afterward."
D. "You can resume normal diet immediately after the procedure."
Correct Answer: B
Rationale: Bronchoscopy requires NPO status for at least 6–8 hours before
the procedure to prevent aspiration. After the procedure, the client remains NPO
until the gag reflex returns to prevent aspiration. The client should not drive due
to sedation. Post-procedure positioning is usually semi-Fowler's to prevent
aspiration.
RESPIRATORY GASTROINTESTINAL DISORDER
METHODOLOGY ACCLAMATION CONSTRUCT 2026.
TOP SCORE A+
SECTION I: RESPIRATORY ASSESSMENT & DIAGNOSTIC TESTING (Questions 1–
25)
1. A nurse is performing a respiratory assessment on a 72-year-old client. Which
of the following findings should the nurse identify as an expected age-related
change?
A. Increased vital capacity
B. Decreased residual volume
C. Decreased chest wall compliance
D. Increased cough reflex
Correct Answer: C
Rationale: Age-related changes in the respiratory system include
decreased chest wall compliance due to calcification of costal cartilages,
weakening of respiratory muscles, and decreased elastic recoil of the lungs. Vital
capacity decreases, residual volume increases, and cough reflex is diminished.
These changes increase the older adult's risk for respiratory infections and
impaired gas exchange.
2. A nurse is assessing a client who reports shortness of breath. Which of the
following questions should the nurse ask first?
A. "When did your shortness of breath begin?"
B. "Do you have any chest pain?"
C. "What medications are you currently taking?"
D. "Have you been exposed to anyone who is sick?"
, Correct Answer: A
Rationale: The priority assessment for a client with dyspnea is to
determine the onset, duration, and pattern of the symptom. Understanding when
the shortness of breath began helps the nurse identify whether this is an acute
emergency (e.g., pulmonary embolism, pneumothorax) or a chronic condition
exacerbation. The other questions are important but secondary to establishing
the timeline of the chief complaint.
3. A nurse is auscultating breath sounds and hears a continuous, musical, high-
pitched sound on expiration. The nurse should document this finding as:
A. Crackles
B. Wheezing
C. Pleural friction rub
D. Rhonchi
Correct Answer: B
Rationale: Wheezing is a continuous, musical, high-pitched sound heard
primarily on expiration and is caused by narrowed airways. It is commonly
associated with asthma, COPD, and bronchospasm. Crackles are discontinuous,
brief sounds heard on inspiration; pleural friction rub is a grating sound heard on
both inspiration and expiration; rhonchi are low-pitched, continuous sounds
caused by secretions in large airways.
4. A nurse is preparing a client for an arterial blood gas (ABG) draw. Which of the
following sites is most commonly used for this procedure?
A. Femoral artery
B. Radial artery
C. Brachial artery
D. Dorsalis pedis artery
Correct Answer: B
, Rationale: The radial artery is the most common site for ABG sampling
because it is superficial, easily accessible, and has collateral circulation via the
ulnar artery. Before the procedure, the nurse should perform the modified Allen
test to verify adequate collateral circulation. The femoral artery is used when
radial access is unavailable but carries higher risk of infection and hematoma.
5. A nurse is reviewing ABG results for a client: pH 7.28, PaCO₂ 58 mm Hg, HCO₃⁻
24 mEq/L. The nurse should interpret these results as:
A. Metabolic acidosis
B. Respiratory alkalosis
C. Respiratory acidosis
D. Metabolic alkalosis
Correct Answer: C
Rationale: A pH below 7.35 indicates acidosis. A PaCO₂ above 45 mm Hg
indicates respiratory acidosis because CO₂ is retained. The normal HCO₃⁻ (22–26
mEq/L) indicates no metabolic compensation has occurred yet, making this
uncompensated respiratory acidosis. Common causes include hypoventilation,
COPD exacerbation, and sedative overdose.
6. A nurse is interpreting an ABG result: pH 7.48, PaCO₂ 30 mm Hg, HCO₃⁻ 22
mEq/L. Which of the following conditions is most consistent with these findings?
A. Opioid overdose
B. Hyperventilation
C. Chronic kidney disease
D. Severe diarrhea
Correct Answer: B
Rationale: The elevated pH (alkalosis) and low PaCO₂ indicate respiratory
alkalosis, which is caused by hyperventilation (blowing off CO₂). This can occur
with anxiety, pain, fever, early sepsis, or pulmonary embolism. Opioid overdose
, causes respiratory acidosis; kidney disease causes metabolic acidosis; severe
diarrhea causes metabolic acidosis.
7. A nurse is preparing to perform a tuberculin skin test (Mantoux test). Which of
the following actions should the nurse take?
A. Inject 0.1 mL of purified protein derivative intradermally
B. Inject 0.5 mL of purified protein derivative subcutaneously
C. Administer the injection into the deltoid muscle
D. Use a 25-gauge needle at a 45-degree angle
Correct Answer: A
Rationale: The Mantoux test involves intradermal injection of 0.1 mL of
purified protein derivative (PPD) into the inner forearm, creating a wheal. A 27-
gauge needle at a 5- to 15-degree angle is used. Subcutaneous or intramuscular
administration is incorrect. The test is read 48–72 hours after administration by
measuring induration (not redness).
8. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the
following instructions should the nurse include in the pre-procedure teaching?
A. "You will need to lie flat for 6 hours after the procedure."
B. "You should not eat or drink anything after midnight."
C. "You will be able to drive yourself home afterward."
D. "You can resume normal diet immediately after the procedure."
Correct Answer: B
Rationale: Bronchoscopy requires NPO status for at least 6–8 hours before
the procedure to prevent aspiration. After the procedure, the client remains NPO
until the gag reflex returns to prevent aspiration. The client should not drive due
to sedation. Post-procedure positioning is usually semi-Fowler's to prevent
aspiration.
