DETAILED ANSWER KEY MEDSURGE
RESPIRATORY LATEST 2025
1.A Nurse Is Admitting a Client Who Has Active Tuberculosis To a Room On a Medical-Surgical Unit. Which Of The
Following Room Assignments Should The Nurse Make For The Client?
A. A Room With Air Exhaust Directly To The Outdoor Environment
Rationale:A Room With Air Exhaust Directly To The Outside Environment Eliminates Contamination Of
Other Client-Care Areas. This Type Of Ventilation System Is Referred To As An Airborne
Infection Isolation Room.
B. A Room With Another Nonsurgical Client
Rationale:A Two-Bed Room With Another Nonsurgical Client Exposes The Other Client To Tuberculosis.
A Client Who Has Tuberculosis Should Have a Private Room.
C. A Room In The Icu
Rationale:A Client Who Has Active Tuberculosis And No Other Comorbidities Is Not Critically Ill.
D. A Room That Is Within View Of The Nurses' Station
Rationale:The Client's Room Should Be Well Ventilated And Private, But It Is Not Necessary For It To Be
Close To The Nurses' Station.
2.A Nurse Is Conducting a Primary Survey Of a Client Who Has Sustained Life-Threatening Injuries Due To a Motor-
Vehicle Crash. Identify The Sequence Of Actions The Nurse Should Take. (Move The Actions Into The Box On The
Right, Placing Them In The Selected Order Of Performance. Use All The Steps.) C. Open The Airway Using a Jaw-
Thrust Maneuver.
D. Determine Effectiveness Of Ventilator Efforts.
B. Establish Iv Access.
A. Perform a Glasgow Coma Scale Assessment.
E. Remove Clothing For a Thorough Assessment.
3.A Nurse Is Caring For a Client Who Has Emphysema. Which Of The Following Findings Should The Nurse Expect
To Assess In This Client? (Select All That Apply.)
A. Dyspnea
B. Bradycardia
, C. Barrel Chest
D. Clubbing Of The Fingers
E. Deep Respirations
Rationale:
Dyspnea Is Correct. Emphysema Is a Lung Disease Involving Damage To The Alveoli In Which
They Become Weakened And Collapse. Dyspnea Is Seen In Clients With Emphysema As The
Lungs Try To Increase The Amount Of Oxygen Available To The
Tissues.</Br></Br>Bradycardia Is Incorrect. With Emphysema, The Heart Rate Will Increase As
The Heart Tries To Compensate For Less Oxygen To The Tissues. </Br></Br>Barrel Chest Is
Correct. Clients With Emphysema Lose Lung Elasticity; The Diaphragm Becomes Permanently
Flattened By Hyperinflation Of The Lungs; The Muscles Of The Rib Cage Become Rigid; And
The Ribs Flare Outward. This Produces The Barrel Chest Typical Of Emphysema
Clients.</Br></Br>Clubbing Of The Fingers Is Correct. Clubbing Results From Chronic Low
Arterial-Oxygen Levels. The Tips Of The Fingers Enlarge And The Nails Become Extremely
Curved From Front To Back.</Br></Br>Deep Respirations Is Incorrect. Clients With
Emphysema Lose Lung Elasticity And Have Muscle Fatigue; Consequently, Respirations
Become Increasingly Shallow.
4.A Nurse Is Caring For a Client Who Has Returned From The Surgical Suite Following Surgery For a Fractured
Mandible. The Client Had Intermaxillary Fixation To Repair And Stabilize The Fracture. Which Of The Following
Actions Is The Priority For The Nurse To Take?
A. Prevent Aspiration.
Rationale:When Using The Airway, Breathing, Circulation Approach To Client Care, The Nurse Should
Determine That The Priority Goal Is To Prevent The Client From Aspirating. Because The Client's Jaws Are
Wired Together, Aspiration Of Emesis Is a Possibility. Therefore, The Client Should Be Given Medication For
Nausea, And Wire Cutters Should Be Kept At The Bedside In Case Of Vomiting. B. Ensure Adequate Nutrition.
Rationale:The Client Should Be Npo Initially After Surgery Until The Gag Reflex Has Returned. Once The
Client Is Able To Eat, The Client May Advance To a Calorie-Appropriate, High-Protein Liquid
Diet. However, This Is Not The Priority At This Time.
C. Promote Oral Hygiene
Rationale:The Client Will Have An Incision Inside The Mouth. While It Is Important That The Client
Receive Frequent Mouth Cleaning, This Is Not The Priority At This Time. D. Relieve The Client's Pain.
Rationale:While The Client May Be In Pain And Will Need To Be Medicated, This Is Not The Priority At This
Time.
5.A Nurse Is Caring For a Client Who Has a New Diagnosis Of Myasthenia Gravis. For Which Of The Following
Manifestations Should The Nurse Monitor?
A. Confusion
Rationale:Myasthenia Gravis Does Not Affect Cognition, Level Of Consciousness, Or Orientation.
, B. Weakness
Rationale:Generalized Weakness Of The Diaphragmatic And Intercostal Muscles May Produce
Respiratory Distress Or Predispose The Client To Respiratory Infections.
C. Increased Intracranial Pressure
Rationale:
Myasthenia Gravis Does Not Affect Pressure Within The Brain.
D. Increased Urinary Output
Rationale:Myasthenia Gravis Does Not Cause Increased Urine Output.
6.A Nurse Is Assessing a Client Who Has a Long History Of Smoking And Is Suspected Of Having Laryngeal Cancer.
The Nurse Should Anticipate That The Client Will Report That Her Earliest Manifestation Was A. Dysphagia.
Rationale:Dysphagia, Difficulty Swallowing, Is a Later Manifestation Of Cancer Of The Larynx. It Occurs As
The Tumor Grows In Size And Impedes The Esophagus. B. Hoarseness.
Rationale:Laryngeal Cancer, a Malignant Tumor Of The Larynx, Is Most Often Caused By Long
Exposure To Tobacco And Alcohol. Hoarseness That Does Not Resolve For Several Weeks Is The Earliest
Manifestation Of Cancer Of The Larynx Because The Tumor Impedes The Action Of The Vocal Cords During
Speech. The Voice May Sound Harsh And Lower In Pitch Than Normal. C. Dyspnea.
Rationale:Dyspnea, Shortness Of Breath, Is a Later Manifestation Of Laryngeal Cancer. It Occurs As The
Tumor Grows In Size And Impedes The Airway Opening. D. Weight Loss.
Rationale:Weight Loss Is a Later Manifestation Of Laryngeal Cancer, Usually Indicative Of Metastasis.
7.A Nurse In The Emergency Department Is Caring For a Client Who Has Extensive Partial And Full-Thickness
Burns Of The Head, Neck, And Chest. While Planning The Client's Care, The Nurse Should Identify Which Of The
Following Risks As The Priority For Assessment And Intervention?
A. Airway Obstruction
Rationale:When Using The Airway, Breathing, Circulation Approach To Client Care, The Nurse Determines
That The Priority Risk Is Airway Obstruction. Burns Of The Head, Neck, And Chest Often
Involve Damage To The Pulmonary Tree Due To Heat As Well As Smoke And Soot Inhalation.
This Can Result In Severe
Respiratory Difficulty. Nursing Measures To Maintain a Patent Airway Should Take Priority In This
Client's Care.
B. Infection
Rationale:Prevention Of Infection Is Essential Throughout Hospitalization And Treatment; However,
Another Risk Is The Priority.
, C. Fluid Imbalance
Rationale:Adequate Fluid Replacement Is Essential Throughout The Acute Phase Of Burn Treatment;
However, Another Risk Is The Priority.
D. Paralytic Ileus
Rationale:Paralytic Ileus Can Develop During The Acute Phase Of Burn Care And Might Require
Nasogastric Decompression; However, Another Risk Is The Priority.
8.A Nurse Is Caring For a Client Who Has Chronic Obstructive Pulmonary Disease (Copd). The Client Tells The
Nurse, "I Can Feel The Congestion In My Lungs, And I Certainly Cough a Lot, But I Can't Seem To Bring Anything
Up." Which Of The Following Actions Should The Nurse Take To Help This Client With Tenacious Bronchial
Secretions?
A. Maintaining a Semi-Fowler's Position As Often As Possible
Rationale:Although a Semi-Fowler's Position Can Help The Client Breathe More Easily, It Will Not Alter
The Consistency Of Secretions.
B. Administering Oxygen Via Nasal Cannula At 2 L/Min
Rationale:Administration Of Oxygen Helps Correct Hypoxemia, But It Will Not Alter The Consistency Of
Secretions.
C. Helping The Client Select a Low-Salt Diet
Rationale:Although a Low-Salt Diet Can Help Limit Peripheral Edema, It Will Not Alter The Consistency
Of Secretions.
D. Encouraging The Client To Drink 2 To 3 L Of Water Daily
Rationale:Copd Is a Term For Two Diseases Of The Respiratory System: Chronic Bronchitis And
Emphysema.
Maintaining Hydration Through The Consumption Of Adequate Fluids Will Help Liquefy Thick
Secretions And Facilitate Their Expectoration.
9.A Nurse Is Observing The Closed Chest Drainage System Of a Client Who Is 24 Hr Post Thoracotomy. The Nurse
Notes Slow, Steady Bubbling In The Suction Control Chamber. Which Of The Following Actions Should The Nurse
Take? A. Check The Tubing Connections For Leaks.
Rationale:This Action Is Used To Determine Why a Water Seal Chamber Has Continuous Bubbling, Not
Slow, Steady Bubbling.
B. Check The Suction Control Outlet On The Wall.
Rationale:This Action Is Used To Determine Why a Suction Control Chamber That Is Hooked To Wall
Suction Has Little Or No Bubbling. C. Clamp The Chest Tube.
Rationale:The Nurse Should Briefly Clamp The Chest Tube To Check For Air Leaks Or To Change The
Drainage System. This Is Not An Appropriate Action For The Nurse To Take At This Time. D. Continue To Monitor
The Client's Respiratory Status.
RESPIRATORY LATEST 2025
1.A Nurse Is Admitting a Client Who Has Active Tuberculosis To a Room On a Medical-Surgical Unit. Which Of The
Following Room Assignments Should The Nurse Make For The Client?
A. A Room With Air Exhaust Directly To The Outdoor Environment
Rationale:A Room With Air Exhaust Directly To The Outside Environment Eliminates Contamination Of
Other Client-Care Areas. This Type Of Ventilation System Is Referred To As An Airborne
Infection Isolation Room.
B. A Room With Another Nonsurgical Client
Rationale:A Two-Bed Room With Another Nonsurgical Client Exposes The Other Client To Tuberculosis.
A Client Who Has Tuberculosis Should Have a Private Room.
C. A Room In The Icu
Rationale:A Client Who Has Active Tuberculosis And No Other Comorbidities Is Not Critically Ill.
D. A Room That Is Within View Of The Nurses' Station
Rationale:The Client's Room Should Be Well Ventilated And Private, But It Is Not Necessary For It To Be
Close To The Nurses' Station.
2.A Nurse Is Conducting a Primary Survey Of a Client Who Has Sustained Life-Threatening Injuries Due To a Motor-
Vehicle Crash. Identify The Sequence Of Actions The Nurse Should Take. (Move The Actions Into The Box On The
Right, Placing Them In The Selected Order Of Performance. Use All The Steps.) C. Open The Airway Using a Jaw-
Thrust Maneuver.
D. Determine Effectiveness Of Ventilator Efforts.
B. Establish Iv Access.
A. Perform a Glasgow Coma Scale Assessment.
E. Remove Clothing For a Thorough Assessment.
3.A Nurse Is Caring For a Client Who Has Emphysema. Which Of The Following Findings Should The Nurse Expect
To Assess In This Client? (Select All That Apply.)
A. Dyspnea
B. Bradycardia
, C. Barrel Chest
D. Clubbing Of The Fingers
E. Deep Respirations
Rationale:
Dyspnea Is Correct. Emphysema Is a Lung Disease Involving Damage To The Alveoli In Which
They Become Weakened And Collapse. Dyspnea Is Seen In Clients With Emphysema As The
Lungs Try To Increase The Amount Of Oxygen Available To The
Tissues.</Br></Br>Bradycardia Is Incorrect. With Emphysema, The Heart Rate Will Increase As
The Heart Tries To Compensate For Less Oxygen To The Tissues. </Br></Br>Barrel Chest Is
Correct. Clients With Emphysema Lose Lung Elasticity; The Diaphragm Becomes Permanently
Flattened By Hyperinflation Of The Lungs; The Muscles Of The Rib Cage Become Rigid; And
The Ribs Flare Outward. This Produces The Barrel Chest Typical Of Emphysema
Clients.</Br></Br>Clubbing Of The Fingers Is Correct. Clubbing Results From Chronic Low
Arterial-Oxygen Levels. The Tips Of The Fingers Enlarge And The Nails Become Extremely
Curved From Front To Back.</Br></Br>Deep Respirations Is Incorrect. Clients With
Emphysema Lose Lung Elasticity And Have Muscle Fatigue; Consequently, Respirations
Become Increasingly Shallow.
4.A Nurse Is Caring For a Client Who Has Returned From The Surgical Suite Following Surgery For a Fractured
Mandible. The Client Had Intermaxillary Fixation To Repair And Stabilize The Fracture. Which Of The Following
Actions Is The Priority For The Nurse To Take?
A. Prevent Aspiration.
Rationale:When Using The Airway, Breathing, Circulation Approach To Client Care, The Nurse Should
Determine That The Priority Goal Is To Prevent The Client From Aspirating. Because The Client's Jaws Are
Wired Together, Aspiration Of Emesis Is a Possibility. Therefore, The Client Should Be Given Medication For
Nausea, And Wire Cutters Should Be Kept At The Bedside In Case Of Vomiting. B. Ensure Adequate Nutrition.
Rationale:The Client Should Be Npo Initially After Surgery Until The Gag Reflex Has Returned. Once The
Client Is Able To Eat, The Client May Advance To a Calorie-Appropriate, High-Protein Liquid
Diet. However, This Is Not The Priority At This Time.
C. Promote Oral Hygiene
Rationale:The Client Will Have An Incision Inside The Mouth. While It Is Important That The Client
Receive Frequent Mouth Cleaning, This Is Not The Priority At This Time. D. Relieve The Client's Pain.
Rationale:While The Client May Be In Pain And Will Need To Be Medicated, This Is Not The Priority At This
Time.
5.A Nurse Is Caring For a Client Who Has a New Diagnosis Of Myasthenia Gravis. For Which Of The Following
Manifestations Should The Nurse Monitor?
A. Confusion
Rationale:Myasthenia Gravis Does Not Affect Cognition, Level Of Consciousness, Or Orientation.
, B. Weakness
Rationale:Generalized Weakness Of The Diaphragmatic And Intercostal Muscles May Produce
Respiratory Distress Or Predispose The Client To Respiratory Infections.
C. Increased Intracranial Pressure
Rationale:
Myasthenia Gravis Does Not Affect Pressure Within The Brain.
D. Increased Urinary Output
Rationale:Myasthenia Gravis Does Not Cause Increased Urine Output.
6.A Nurse Is Assessing a Client Who Has a Long History Of Smoking And Is Suspected Of Having Laryngeal Cancer.
The Nurse Should Anticipate That The Client Will Report That Her Earliest Manifestation Was A. Dysphagia.
Rationale:Dysphagia, Difficulty Swallowing, Is a Later Manifestation Of Cancer Of The Larynx. It Occurs As
The Tumor Grows In Size And Impedes The Esophagus. B. Hoarseness.
Rationale:Laryngeal Cancer, a Malignant Tumor Of The Larynx, Is Most Often Caused By Long
Exposure To Tobacco And Alcohol. Hoarseness That Does Not Resolve For Several Weeks Is The Earliest
Manifestation Of Cancer Of The Larynx Because The Tumor Impedes The Action Of The Vocal Cords During
Speech. The Voice May Sound Harsh And Lower In Pitch Than Normal. C. Dyspnea.
Rationale:Dyspnea, Shortness Of Breath, Is a Later Manifestation Of Laryngeal Cancer. It Occurs As The
Tumor Grows In Size And Impedes The Airway Opening. D. Weight Loss.
Rationale:Weight Loss Is a Later Manifestation Of Laryngeal Cancer, Usually Indicative Of Metastasis.
7.A Nurse In The Emergency Department Is Caring For a Client Who Has Extensive Partial And Full-Thickness
Burns Of The Head, Neck, And Chest. While Planning The Client's Care, The Nurse Should Identify Which Of The
Following Risks As The Priority For Assessment And Intervention?
A. Airway Obstruction
Rationale:When Using The Airway, Breathing, Circulation Approach To Client Care, The Nurse Determines
That The Priority Risk Is Airway Obstruction. Burns Of The Head, Neck, And Chest Often
Involve Damage To The Pulmonary Tree Due To Heat As Well As Smoke And Soot Inhalation.
This Can Result In Severe
Respiratory Difficulty. Nursing Measures To Maintain a Patent Airway Should Take Priority In This
Client's Care.
B. Infection
Rationale:Prevention Of Infection Is Essential Throughout Hospitalization And Treatment; However,
Another Risk Is The Priority.
, C. Fluid Imbalance
Rationale:Adequate Fluid Replacement Is Essential Throughout The Acute Phase Of Burn Treatment;
However, Another Risk Is The Priority.
D. Paralytic Ileus
Rationale:Paralytic Ileus Can Develop During The Acute Phase Of Burn Care And Might Require
Nasogastric Decompression; However, Another Risk Is The Priority.
8.A Nurse Is Caring For a Client Who Has Chronic Obstructive Pulmonary Disease (Copd). The Client Tells The
Nurse, "I Can Feel The Congestion In My Lungs, And I Certainly Cough a Lot, But I Can't Seem To Bring Anything
Up." Which Of The Following Actions Should The Nurse Take To Help This Client With Tenacious Bronchial
Secretions?
A. Maintaining a Semi-Fowler's Position As Often As Possible
Rationale:Although a Semi-Fowler's Position Can Help The Client Breathe More Easily, It Will Not Alter
The Consistency Of Secretions.
B. Administering Oxygen Via Nasal Cannula At 2 L/Min
Rationale:Administration Of Oxygen Helps Correct Hypoxemia, But It Will Not Alter The Consistency Of
Secretions.
C. Helping The Client Select a Low-Salt Diet
Rationale:Although a Low-Salt Diet Can Help Limit Peripheral Edema, It Will Not Alter The Consistency
Of Secretions.
D. Encouraging The Client To Drink 2 To 3 L Of Water Daily
Rationale:Copd Is a Term For Two Diseases Of The Respiratory System: Chronic Bronchitis And
Emphysema.
Maintaining Hydration Through The Consumption Of Adequate Fluids Will Help Liquefy Thick
Secretions And Facilitate Their Expectoration.
9.A Nurse Is Observing The Closed Chest Drainage System Of a Client Who Is 24 Hr Post Thoracotomy. The Nurse
Notes Slow, Steady Bubbling In The Suction Control Chamber. Which Of The Following Actions Should The Nurse
Take? A. Check The Tubing Connections For Leaks.
Rationale:This Action Is Used To Determine Why a Water Seal Chamber Has Continuous Bubbling, Not
Slow, Steady Bubbling.
B. Check The Suction Control Outlet On The Wall.
Rationale:This Action Is Used To Determine Why a Suction Control Chamber That Is Hooked To Wall
Suction Has Little Or No Bubbling. C. Clamp The Chest Tube.
Rationale:The Nurse Should Briefly Clamp The Chest Tube To Check For Air Leaks Or To Change The
Drainage System. This Is Not An Appropriate Action For The Nurse To Take At This Time. D. Continue To Monitor
The Client's Respiratory Status.
