Respiratory NCLEX questions with complete solutions
A client is being prepared for a thoracentesis. The nurse assigned to care for the client assists the
client to which of the following positions for the procedure? Correct Answer: Lying in bed on
the unaffected side with the head of the bed elevated 45 degrees
A nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the
client becomes restless and tachycardic. What should the nurse do? Correct Answer:
Discontinue suctioning until the client is stabilized and monitor vital signs.
A nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes
fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action
would be appropriate? Correct Answer: Continue to monitor, because this is an expected
finding.
A nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse
instructs the client to do which of the following during this process? Correct Answer: Perform
Valsalva's maneuver. (i.e., take a deep breath, exhale, and bear down), the tube is quickly
withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the
client to take a deep breath and hold the breath while the tube is removed.
A nurse is assisting in caring for a client with a chest tube. The nurse understands that which of
the following is an incorrect action for the care of the client? Correct Answer: Pin the tubing to
the bed linens
A nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the
client for crepitus (subcutaneous emphysema). The nurse monitors the client for this
complication by: Correct Answer: Palpating for the leakage of air into the subcutaneous tissues
fenestrated tracheostomy tube Correct Answer: Enables the client to speak
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client
who just returned from the recovery room after a thoracotomy with wedge resection. Which
findings would the nurse expect to note? Select all that apply. Correct Answer: 50 mL of
drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
A nurse is providing instructions to a hospitalized client with a diagnosis of emphysema about
positions that will enhance the effectiveness of breathing during dyspneic periods. Which
position will the nurse instruct the client to assume? Correct Answer: Sitting on the side of the
bed, leaning on an overbed table
,A nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse reviews the
results of which diagnostic test that will confirm this diagnosis? Correct Answer: Sputum
culture
A nurse is caring for a client with emphysema who is receiving oxygen. The nurse checks the
oxygen flow rate to ensure that it does not exceed: Correct Answer: 2 L/min
A nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its
purpose. The nurse tells the client that the primary purpose of pursed lip breathing is to Correct
Answer: Promote carbon dioxide elimination.
The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts
to determine the cause of the alarm but is unsuccessful. Which initial action will the nurse take?
Correct Answer: Ventilate the client manually. If an alarm is sounding at any time and the nurse
cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual
resuscitation device is used to support respirations until the problem can be corrected.
low-pressure alarm Correct Answer: A disconnection or a cuff leak can result in the sounding of
the low-pressure alarm
high-pressure alarm Correct Answer: When the high-pressure alarm sounds on a ventilator, it is
most likely caused by an obstruction. The obstruction can be caused by the client biting on the
tube, kinking of the tubing, or mucus plugging requiring suctioning. It is also important to check
the tubing for the presence of any water and determine whether the client is out of rhythm with
breathing with the ventilator.
A nurse is assigned to care for a client after a left pneumonectomy. Which one of the follow
positions would be contraindicated for this client? Correct Answer: On the side
A nurse is caring for a client after pulmonary angiography via catheter insertion into the left
groin. The nurse monitors for an allergic reaction to the contrast medium by noting the presence
of: Correct Answer: Signs of allergic reaction to the contrast medium include localized itching
and edema, respiratory distress, stridor, and decreased blood pressure.
A nurse is providing discharge instructions to the client with pulmonary sarcoidosis. The nurse
knows that the client understands the information if the client verbalizes which early sign of
exacerbation? Correct Answer: Shortness of breath is an early sign of exacerbation of
pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic
signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight
loss.
Risk for TB Correct Answer: People at high risk for acquiring tuberculosis include children
younger than 5 years of age; homeless individuals or those from a lower socioeconomic group,
minority groups, or immigrant group; individuals in constant, frequent contact with an untreated
or undiagnosed individual; individuals living in crowded areas, such as long-term care facilities,
, prisons, and mental health facilities; older clients; individuals with malnutrition, an infection, or
an immune dysfunction or human immunodeficiency virus infection, or individuals who are
immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are
intravenous drug users.
A nurse is reading the results of a Mantoux skin test on a client with no documented health
problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that
the result is: Correct Answer: A positive Mantoux reading has an induration measuring 10 mm
or more in diameter and indicates exposure to tuberculosis. A small area of ecchymosis is
insignificant and is probably related to injection technique.
A nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux skin
test. Which action by the nurse is the priority? Correct Answer: The nurse who interprets a
Mantoux skin test as positive notifies the health care provider (HCP) immediately. The HCP
would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis
(TB) or old, healed lesions. A sputum culture would be done to confirm the diagnosis of active
TB. The client is placed on TB precautions prophylactically until a final diagnosis is made
A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is
worried about the possibility of infecting the family and others. The nurse determines that the
client would get the most reassurance from the knowledge that: Correct Answer: Family
members or others who have been in close contact with a client diagnosed with TB are placed on
prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client is usually not
contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take
the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant TB.
A nurse has reinforced discharge teaching with a client who was diagnosed with tuberculosis
(TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood
the information if the client makes which statement? Correct Answer: "I should not be
contagious after 2 to 3 weeks of medication therapy."
When can the client dx wit TB go back to work? Correct Answer: The client is allowed to return
to employment when the results of three sputum cultures are negative.
When to take sputum culture for TB? Correct Answer: The client is informed that a sputum
culture is needed every 2 to 4 weeks
Is respiratory isolation necessary Correct Answer: The client and family are informed that
respiratory isolation is not necessary, because family members have already been exposed
A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which
intervention(s) would the nurse perform for this procedure? Correct Answer: Intermittent
suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should
hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source
before suctioning because suction depletes the client's oxygen supply. The catheter should be
inserted quickly and gently until resistance is met or the client coughs; then pulled back 1 cm or
A client is being prepared for a thoracentesis. The nurse assigned to care for the client assists the
client to which of the following positions for the procedure? Correct Answer: Lying in bed on
the unaffected side with the head of the bed elevated 45 degrees
A nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the
client becomes restless and tachycardic. What should the nurse do? Correct Answer:
Discontinue suctioning until the client is stabilized and monitor vital signs.
A nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes
fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action
would be appropriate? Correct Answer: Continue to monitor, because this is an expected
finding.
A nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse
instructs the client to do which of the following during this process? Correct Answer: Perform
Valsalva's maneuver. (i.e., take a deep breath, exhale, and bear down), the tube is quickly
withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the
client to take a deep breath and hold the breath while the tube is removed.
A nurse is assisting in caring for a client with a chest tube. The nurse understands that which of
the following is an incorrect action for the care of the client? Correct Answer: Pin the tubing to
the bed linens
A nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the
client for crepitus (subcutaneous emphysema). The nurse monitors the client for this
complication by: Correct Answer: Palpating for the leakage of air into the subcutaneous tissues
fenestrated tracheostomy tube Correct Answer: Enables the client to speak
A nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client
who just returned from the recovery room after a thoracotomy with wedge resection. Which
findings would the nurse expect to note? Select all that apply. Correct Answer: 50 mL of
drainage in the drainage-collection chamber
The drainage system is maintained below the client's chest.
An occlusive dressing is in place over the chest-tube insertion site.
Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation
A nurse is providing instructions to a hospitalized client with a diagnosis of emphysema about
positions that will enhance the effectiveness of breathing during dyspneic periods. Which
position will the nurse instruct the client to assume? Correct Answer: Sitting on the side of the
bed, leaning on an overbed table
,A nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse reviews the
results of which diagnostic test that will confirm this diagnosis? Correct Answer: Sputum
culture
A nurse is caring for a client with emphysema who is receiving oxygen. The nurse checks the
oxygen flow rate to ensure that it does not exceed: Correct Answer: 2 L/min
A nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its
purpose. The nurse tells the client that the primary purpose of pursed lip breathing is to Correct
Answer: Promote carbon dioxide elimination.
The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts
to determine the cause of the alarm but is unsuccessful. Which initial action will the nurse take?
Correct Answer: Ventilate the client manually. If an alarm is sounding at any time and the nurse
cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual
resuscitation device is used to support respirations until the problem can be corrected.
low-pressure alarm Correct Answer: A disconnection or a cuff leak can result in the sounding of
the low-pressure alarm
high-pressure alarm Correct Answer: When the high-pressure alarm sounds on a ventilator, it is
most likely caused by an obstruction. The obstruction can be caused by the client biting on the
tube, kinking of the tubing, or mucus plugging requiring suctioning. It is also important to check
the tubing for the presence of any water and determine whether the client is out of rhythm with
breathing with the ventilator.
A nurse is assigned to care for a client after a left pneumonectomy. Which one of the follow
positions would be contraindicated for this client? Correct Answer: On the side
A nurse is caring for a client after pulmonary angiography via catheter insertion into the left
groin. The nurse monitors for an allergic reaction to the contrast medium by noting the presence
of: Correct Answer: Signs of allergic reaction to the contrast medium include localized itching
and edema, respiratory distress, stridor, and decreased blood pressure.
A nurse is providing discharge instructions to the client with pulmonary sarcoidosis. The nurse
knows that the client understands the information if the client verbalizes which early sign of
exacerbation? Correct Answer: Shortness of breath is an early sign of exacerbation of
pulmonary sarcoidosis. Others include chest pain, hemoptysis, and pneumothorax. Systemic
signs and symptoms that occur later include weakness and fatigue, malaise, fever, and weight
loss.
Risk for TB Correct Answer: People at high risk for acquiring tuberculosis include children
younger than 5 years of age; homeless individuals or those from a lower socioeconomic group,
minority groups, or immigrant group; individuals in constant, frequent contact with an untreated
or undiagnosed individual; individuals living in crowded areas, such as long-term care facilities,
, prisons, and mental health facilities; older clients; individuals with malnutrition, an infection, or
an immune dysfunction or human immunodeficiency virus infection, or individuals who are
immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are
intravenous drug users.
A nurse is reading the results of a Mantoux skin test on a client with no documented health
problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that
the result is: Correct Answer: A positive Mantoux reading has an induration measuring 10 mm
or more in diameter and indicates exposure to tuberculosis. A small area of ecchymosis is
insignificant and is probably related to injection technique.
A nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux skin
test. Which action by the nurse is the priority? Correct Answer: The nurse who interprets a
Mantoux skin test as positive notifies the health care provider (HCP) immediately. The HCP
would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis
(TB) or old, healed lesions. A sputum culture would be done to confirm the diagnosis of active
TB. The client is placed on TB precautions prophylactically until a final diagnosis is made
A client being discharged from the hospital to home with a diagnosis of tuberculosis (TB) is
worried about the possibility of infecting the family and others. The nurse determines that the
client would get the most reassurance from the knowledge that: Correct Answer: Family
members or others who have been in close contact with a client diagnosed with TB are placed on
prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client is usually not
contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take
the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant TB.
A nurse has reinforced discharge teaching with a client who was diagnosed with tuberculosis
(TB) and has been on medication for 1½ weeks. The nurse knows that the client has understood
the information if the client makes which statement? Correct Answer: "I should not be
contagious after 2 to 3 weeks of medication therapy."
When can the client dx wit TB go back to work? Correct Answer: The client is allowed to return
to employment when the results of three sputum cultures are negative.
When to take sputum culture for TB? Correct Answer: The client is informed that a sputum
culture is needed every 2 to 4 weeks
Is respiratory isolation necessary Correct Answer: The client and family are informed that
respiratory isolation is not necessary, because family members have already been exposed
A nurse is preparing to suction an adult client through the client's tracheostomy tube. Which
intervention(s) would the nurse perform for this procedure? Correct Answer: Intermittent
suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should
hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source
before suctioning because suction depletes the client's oxygen supply. The catheter should be
inserted quickly and gently until resistance is met or the client coughs; then pulled back 1 cm or
