Respiratory System NCLEX questions
The most important action the nurse should do before and after suctioning a client is:
a. Placing the client in a supine position
b. Making sure that suctioning takes only 10-15 seconds
c. Evaluating for clear breath sounds
d. Hyperventilating the client with 100% oxygen
d. Hyperventilating the client with 100% oxygen
The position of a conscious client during suctioning is:
a. Fowler's
b. Supine position
c. Side-lying
d. Prone
a. Fowler's
Position a conscious person who has a functional gag reflex in the semi fowler's position with the head
turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client
is unconscious place the patient a lateral position facing you.
Presence of overdistended and non-functional alveoli is a condition called:
a. Bronchitis
b. Emphysema
c. Empyema
d. Atelectasis
Answer: B.
,An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse
of a part or the whole lung. Empyema is the presence of pus in the lung.
23. The accumulation of fluids in the pleural space is called:
a. Pleural effusion
b. Hemothorax
c. Hydrothorax
d. Pyothorax
a. Pleural effusion
2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suction control chamber. What action is appropriate?
a. Do nothing, because this is an expected finding.
b. Immediately clamp the chest tube and notify the physician.
c. Check for an air leak because the bubbling should be intermittent.
d. Increase the suction pressure so that bubbling becomes vigorous.
Answer A.
Continuous gentle bubbling should be noted in the suction control chamber.
Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing
drainage devices (according to agency policy).
Option C is incorrect. Bubbling should be continuous and not intermittent.
Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases
the rate of evaporation of water in the drainage system.
, 4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action is to:
a. Call the physician.
b. Place the tube in a bottle of sterile water.
c. Immediately replace the chest tube system.
d. Place the sterile dressing over the disconnection site.
Answer B.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water
held below the level of the chest. The system is replaced if it breaks or cracks or if the collection
chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications
resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The
initial nursing action is to:
a. Call the physician to reinsert the tube.
b. Grasp the retention sutures to spread the opening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.
b. Grasp the retention sutures to spread the opening.
A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse
reports which of the following signs immediately if experienced by the client?
a. Stridor
b. Occasional pink-tinged sputum
c. A few basilar lung crackles on the right
d. Respiratory rate of 24 breaths/min
The most important action the nurse should do before and after suctioning a client is:
a. Placing the client in a supine position
b. Making sure that suctioning takes only 10-15 seconds
c. Evaluating for clear breath sounds
d. Hyperventilating the client with 100% oxygen
d. Hyperventilating the client with 100% oxygen
The position of a conscious client during suctioning is:
a. Fowler's
b. Supine position
c. Side-lying
d. Prone
a. Fowler's
Position a conscious person who has a functional gag reflex in the semi fowler's position with the head
turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client
is unconscious place the patient a lateral position facing you.
Presence of overdistended and non-functional alveoli is a condition called:
a. Bronchitis
b. Emphysema
c. Empyema
d. Atelectasis
Answer: B.
,An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse
of a part or the whole lung. Empyema is the presence of pus in the lung.
23. The accumulation of fluids in the pleural space is called:
a. Pleural effusion
b. Hemothorax
c. Hydrothorax
d. Pyothorax
a. Pleural effusion
2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suction control chamber. What action is appropriate?
a. Do nothing, because this is an expected finding.
b. Immediately clamp the chest tube and notify the physician.
c. Check for an air leak because the bubbling should be intermittent.
d. Increase the suction pressure so that bubbling becomes vigorous.
Answer A.
Continuous gentle bubbling should be noted in the suction control chamber.
Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing
drainage devices (according to agency policy).
Option C is incorrect. Bubbling should be continuous and not intermittent.
Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases
the rate of evaporation of water in the drainage system.
, 4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action is to:
a. Call the physician.
b. Place the tube in a bottle of sterile water.
c. Immediately replace the chest tube system.
d. Place the sterile dressing over the disconnection site.
Answer B.
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water
held below the level of the chest. The system is replaced if it breaks or cracks or if the collection
chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications
resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The
initial nursing action is to:
a. Call the physician to reinsert the tube.
b. Grasp the retention sutures to spread the opening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.
b. Grasp the retention sutures to spread the opening.
A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse
reports which of the following signs immediately if experienced by the client?
a. Stridor
b. Occasional pink-tinged sputum
c. A few basilar lung crackles on the right
d. Respiratory rate of 24 breaths/min
