Adult Health Nursing I – Unit 1 2026/2027
Exam Questions & Answers + Rationale
Question 1:
A nurse is assessing a client admitted with an acute respiratory disorder. Which
assessment finding requires the most immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 84%
C. Productive cough with clear sputum
D. Mild chest discomfort when coughing
Correct Answer: B. Oxygen saturation of 84%
Rationale:
An oxygen saturation of 84% indicates significant hypoxemia and requires
immediate attention. Airway and breathing are prioritized before less urgent
findings. The nurse should assess respiratory effort, apply prescribed oxygen, and
escalate care if oxygenation does not improve.
Question 2:
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. Which oxygen saturation range is commonly targeted for a client at risk of
chronic carbon dioxide retention?
A. 70%–75%
B. 80%–84%
,C. 88%–92%
D. 98%–100%
Correct Answer: C. 88%–92%
Rationale:
Clients with COPD who are at risk for chronic carbon dioxide retention are often
maintained at an oxygen saturation of approximately 88%–92%, depending on the
prescribed target. Excessive oxygen administration may worsen hypercapnia in
some susceptible clients.
Question 3:
A client with pneumonia has a temperature of 39.1°C, productive cough, crackles,
and increasing fatigue. Which intervention is most important for evaluating the
client's respiratory status?
A. Assess oxygen saturation
B. Measure abdominal circumference
C. Check bowel sounds
D. Assess peripheral pulses only
Correct Answer: A. Assess oxygen saturation
Rationale:
Pneumonia can impair gas exchange because inflammation and secretions interfere
with ventilation and oxygen diffusion. Oxygen saturation provides important
information about the client's current oxygenation status and helps determine
whether additional respiratory support is required.
,Question 4:
A client with asthma develops severe wheezing and difficulty speaking. Which
medication should the nurse expect to administer for rapid relief?
A. Albuterol
B. Montelukast
C. Fluticasone
D. Salmeterol
Correct Answer: A. Albuterol
Rationale:
Albuterol is a short-acting beta2-adrenergic agonist that produces rapid
bronchodilation and is commonly used for acute asthma symptoms. Inhaled
corticosteroids and leukotriene modifiers are primarily controller medications and
do not provide the same immediate relief.
Question 5:
A client with COPD asks why pursed-lip breathing is recommended. Which
explanation is most appropriate?
A. It increases respiratory rate
B. It helps keep airways open during exhalation
C. It increases mucus production
D. It prevents oxygen absorption
Correct Answer: B. It helps keep airways open during exhalation
Rationale:
Pursed-lip breathing creates mild positive pressure during exhalation, helping
, prevent premature airway collapse and reducing air trapping. It can improve
ventilation and decrease the sensation of breathlessness, particularly in clients with
emphysema and other forms of COPD.
Question 6:
A client with pneumonia has thick respiratory secretions. Which intervention is
most appropriate if there is no fluid restriction?
A. Encourage adequate fluid intake
B. Restrict oral fluids
C. Keep the client on strict bed rest
D. Discourage coughing
Correct Answer: A. Encourage adequate fluid intake
Rationale:
Adequate hydration helps thin respiratory secretions, making them easier to cough
up. Unless contraindicated by conditions such as heart or renal failure, appropriate
fluid intake supports airway clearance. Positioning, coughing exercises, and
prescribed respiratory treatments may also help.
Question 7:
A client with COPD becomes increasingly dyspneic while walking. Which
instruction should the nurse provide?
A. Hold the breath during activity
B. Breathe rapidly through the mouth
C. Exhale slowly through pursed lips
D. Stop breathing briefly after inspiration
Exam Questions & Answers + Rationale
Question 1:
A nurse is assessing a client admitted with an acute respiratory disorder. Which
assessment finding requires the most immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 84%
C. Productive cough with clear sputum
D. Mild chest discomfort when coughing
Correct Answer: B. Oxygen saturation of 84%
Rationale:
An oxygen saturation of 84% indicates significant hypoxemia and requires
immediate attention. Airway and breathing are prioritized before less urgent
findings. The nurse should assess respiratory effort, apply prescribed oxygen, and
escalate care if oxygenation does not improve.
Question 2:
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy. Which oxygen saturation range is commonly targeted for a client at risk of
chronic carbon dioxide retention?
A. 70%–75%
B. 80%–84%
,C. 88%–92%
D. 98%–100%
Correct Answer: C. 88%–92%
Rationale:
Clients with COPD who are at risk for chronic carbon dioxide retention are often
maintained at an oxygen saturation of approximately 88%–92%, depending on the
prescribed target. Excessive oxygen administration may worsen hypercapnia in
some susceptible clients.
Question 3:
A client with pneumonia has a temperature of 39.1°C, productive cough, crackles,
and increasing fatigue. Which intervention is most important for evaluating the
client's respiratory status?
A. Assess oxygen saturation
B. Measure abdominal circumference
C. Check bowel sounds
D. Assess peripheral pulses only
Correct Answer: A. Assess oxygen saturation
Rationale:
Pneumonia can impair gas exchange because inflammation and secretions interfere
with ventilation and oxygen diffusion. Oxygen saturation provides important
information about the client's current oxygenation status and helps determine
whether additional respiratory support is required.
,Question 4:
A client with asthma develops severe wheezing and difficulty speaking. Which
medication should the nurse expect to administer for rapid relief?
A. Albuterol
B. Montelukast
C. Fluticasone
D. Salmeterol
Correct Answer: A. Albuterol
Rationale:
Albuterol is a short-acting beta2-adrenergic agonist that produces rapid
bronchodilation and is commonly used for acute asthma symptoms. Inhaled
corticosteroids and leukotriene modifiers are primarily controller medications and
do not provide the same immediate relief.
Question 5:
A client with COPD asks why pursed-lip breathing is recommended. Which
explanation is most appropriate?
A. It increases respiratory rate
B. It helps keep airways open during exhalation
C. It increases mucus production
D. It prevents oxygen absorption
Correct Answer: B. It helps keep airways open during exhalation
Rationale:
Pursed-lip breathing creates mild positive pressure during exhalation, helping
, prevent premature airway collapse and reducing air trapping. It can improve
ventilation and decrease the sensation of breathlessness, particularly in clients with
emphysema and other forms of COPD.
Question 6:
A client with pneumonia has thick respiratory secretions. Which intervention is
most appropriate if there is no fluid restriction?
A. Encourage adequate fluid intake
B. Restrict oral fluids
C. Keep the client on strict bed rest
D. Discourage coughing
Correct Answer: A. Encourage adequate fluid intake
Rationale:
Adequate hydration helps thin respiratory secretions, making them easier to cough
up. Unless contraindicated by conditions such as heart or renal failure, appropriate
fluid intake supports airway clearance. Positioning, coughing exercises, and
prescribed respiratory treatments may also help.
Question 7:
A client with COPD becomes increasingly dyspneic while walking. Which
instruction should the nurse provide?
A. Hold the breath during activity
B. Breathe rapidly through the mouth
C. Exhale slowly through pursed lips
D. Stop breathing briefly after inspiration
