NCLEX-PN Respiratory
1. The nurse is caring for a newly admitted client with pneumonia.The primaryhealth care
provider has prescribed a sputum specimen for culture and sensi-tivity.The nurse should
perform the actions concerning the sputum collectionin which priority order? Arrange the
actions in the order that they should be performed. All options must be used.
Send the specimen immediately to the laboratory.
Administer the prescribed antibiotic
Obtain and label a sterile container.
Have the client brush teeth and rinse mouth with water. Have the client take several deep
breaths before coughing.
Have the client expectorate sputum (not saliva) into sterile container.: 1Obtain and label a
sterile container.
2
Have the client brush teeth and rinse mouth with water.
3
Have the client take several deep breaths before coughing.
4
Have the client expectorate sputum (not saliva) into sterile container.
5
Send the specimen immediately to the laboratory.
6
,Administer the prescribed antibiotic
2. A client with acquired immunodeficiency syndrome (AIDS) has histoplas-mosis. Which
sign/symptom should the nurse expect the client to experi- ence?
1.Dyspnea 2.Headache 3.Weight gain 4.Hypothermia: 1
(Rationale:
Histoplasmosis is an opportunistic fungal infection that can occur in the clientwith AIDS. The
infection begins as a respiratory infection and can progress to
disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight
loss. There may be an enlargement of the client's lymph nodes, liver, andspleen as well.)
3. A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The
nurse determines that the client is experiencing complications of the procedure if the nurse
notes which sign/symptom?
1.Oxygen saturation of 95% 2.Weak gag and cough reflex
3. Respiratory rate of 22 breaths per minute 4.Breath sounds greater on the right than the left:
4
(Rationale:
Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the
primary health care provider. A weak cough and gag reflex 1 hourpostprocedure is an
expected finding because of residual effects of intravenous sedation and local anesthesia. A
respiratory rate of 22 breaths per minute and anoxygen saturation of 95% are acceptable
measurements.)
4. The nurse is caring for a hospitalized client with a suspected diagnosis oftuberculosis (TB).
Which finding does the nurse expect to note during data collection?
1. High fever
2. Chills and night sweats3.Complaints of diarrhea
4. Petechiae on the upper extremities: 2
(Rationale:
The client with tuberculosis usually experiences cough (either productive or nonpro-ductive),
,fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and
sweats (which may occur at night), and a low-grade fever.)
5. A client arrives in the emergency department with a bloody nose. Which isthe initial
nursing action?
1.Place the client in a supine position. 2.Apply an ice collar around the client's neck.
3. Assist the client to a sitting position with the head tilted slightly forward.
4. Instruct the client to swallow the blood until the bleeding can be controlled.-
:3
(Rationale:
The initial nursing action to treat the client with a bloody nose is to loosen clothing around the
neck to prevent pressure on the carotid artery. The client should be assisted to a sitting
position with the head tilted slightly forward, and pressure should be applied to the nares by
pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and
forehead. If these actions are not successful in controlling the bleeding, an ice collar may be
applied along with a topical vasoconstrictive medication. The primary health care provider
may also prescribe packing to the nostrils. The client should be provided with an emesis basin
and should be instructed not to swallow blood to reduce the risk of nausea and vomiting.)
6. In which area of the chest should the nurse expect to auscultate this breathsound? (Refer to
audio.)
1. Over the trachea
2. Over the peripheral lung fields 3.Posteriorly at T4 medial to the scapula
4.Between the first and second intercostal spaces at the sternal borderanteriorly: 2
(Rationale:
Breath sounds are noises resulting from the transmission of vibrations produced by the
movement of air in the respiratory passages. Normal breath sounds includebronchovesicular
sounds, vesicular breath sounds, and bronchial breath sounds.
The sounds that the nurse hears are vesicular breath sounds. Vesicular breath sounds normally
are heard over the lesser bronchi, bronchioles, and lobes (periph-eral lung fields). These
sounds are soft and low pitched and resemble a sighing or gentle rustling, and the inspiration
, phase is longer than the expiration phase. Bron-chovesicular breath sounds normally are heard
over the first and second intercostalspaces at the sternal border anteriorly and at T4 medial to
the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and
vesicular breathsounds and are moderately pitched with a medium intensity. The inspiration
and expiration phases are equal. Bronchial breath sounds are loud, high-pitched soundsthat
resemble air blowing through a hollow pipe. The expiration phase is louder and longer than
the inspiration phase, and there is a distinct pause between the inspiration and expiration
phase. Bronchial breath sounds are heard normally overthe manubrium.)
7. The nurse is preparing a plan of care for the client who will be returning from
surgery following a right lung wedge resection. Included in the plan of care isthat in the
postoperative period, the nurse should avoid which positioning?
1.In low-Fowler's 2.In semi-Fowler's 3.On the left side 4.On the right side: 4(Rationale:
Following a wedge resection, the client should not be placed on the operative side. Lying on
the operative side hinders expansion of remaining lung tissue and
may accentuate perfusion of poorly ventilated tissue. This further impedes normalgas
exchange. In addition, complete lateral turning may be contraindicated. The surgeon's
prescriptions for positioning after this surgical procedure are always followed.)
8. The nurse is caring for an older client who is on bed rest. The nurse planswhich intervention
to prevent respiratory complications?
1.Decreasing oral fluid intake 2.Monitoring the vital signs every shift
3. Changing the client's position every 2 hours
4. Instructing the client to bear down every hour and to hold his or her breath: 3(Rationale:
Frequent position changes help mobilize lung secretions and prevent pooling. Thisis the only
intervention identified in the options that will prevent respiratory compli- cations. The nurse
should encourage fluid intake to thin secretions and thus enablethe client to expectorate more
easily. It is important to encourage coughing and deep breathing to mobilize lung secretions.
The nurse should assess the client's vitalsigns every 4 hours to identify an elevated temperature,
which may suggest infection.The client should be instructed to avoid the Valsalva maneuver or
any activity that involves holding the breath.)
9. The nurse notes that a hospitalized client has experienced a positive reac-tion to the
tuberculin skin test. Which action by the nurse is priority?
1. Report the findings.
1. The nurse is caring for a newly admitted client with pneumonia.The primaryhealth care
provider has prescribed a sputum specimen for culture and sensi-tivity.The nurse should
perform the actions concerning the sputum collectionin which priority order? Arrange the
actions in the order that they should be performed. All options must be used.
Send the specimen immediately to the laboratory.
Administer the prescribed antibiotic
Obtain and label a sterile container.
Have the client brush teeth and rinse mouth with water. Have the client take several deep
breaths before coughing.
Have the client expectorate sputum (not saliva) into sterile container.: 1Obtain and label a
sterile container.
2
Have the client brush teeth and rinse mouth with water.
3
Have the client take several deep breaths before coughing.
4
Have the client expectorate sputum (not saliva) into sterile container.
5
Send the specimen immediately to the laboratory.
6
,Administer the prescribed antibiotic
2. A client with acquired immunodeficiency syndrome (AIDS) has histoplas-mosis. Which
sign/symptom should the nurse expect the client to experi- ence?
1.Dyspnea 2.Headache 3.Weight gain 4.Hypothermia: 1
(Rationale:
Histoplasmosis is an opportunistic fungal infection that can occur in the clientwith AIDS. The
infection begins as a respiratory infection and can progress to
disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight
loss. There may be an enlargement of the client's lymph nodes, liver, andspleen as well.)
3. A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The
nurse determines that the client is experiencing complications of the procedure if the nurse
notes which sign/symptom?
1.Oxygen saturation of 95% 2.Weak gag and cough reflex
3. Respiratory rate of 22 breaths per minute 4.Breath sounds greater on the right than the left:
4
(Rationale:
Asymmetrical breath sounds could indicate pneumothorax, and this should be reported to the
primary health care provider. A weak cough and gag reflex 1 hourpostprocedure is an
expected finding because of residual effects of intravenous sedation and local anesthesia. A
respiratory rate of 22 breaths per minute and anoxygen saturation of 95% are acceptable
measurements.)
4. The nurse is caring for a hospitalized client with a suspected diagnosis oftuberculosis (TB).
Which finding does the nurse expect to note during data collection?
1. High fever
2. Chills and night sweats3.Complaints of diarrhea
4. Petechiae on the upper extremities: 2
(Rationale:
The client with tuberculosis usually experiences cough (either productive or nonpro-ductive),
,fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and
sweats (which may occur at night), and a low-grade fever.)
5. A client arrives in the emergency department with a bloody nose. Which isthe initial
nursing action?
1.Place the client in a supine position. 2.Apply an ice collar around the client's neck.
3. Assist the client to a sitting position with the head tilted slightly forward.
4. Instruct the client to swallow the blood until the bleeding can be controlled.-
:3
(Rationale:
The initial nursing action to treat the client with a bloody nose is to loosen clothing around the
neck to prevent pressure on the carotid artery. The client should be assisted to a sitting
position with the head tilted slightly forward, and pressure should be applied to the nares by
pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and
forehead. If these actions are not successful in controlling the bleeding, an ice collar may be
applied along with a topical vasoconstrictive medication. The primary health care provider
may also prescribe packing to the nostrils. The client should be provided with an emesis basin
and should be instructed not to swallow blood to reduce the risk of nausea and vomiting.)
6. In which area of the chest should the nurse expect to auscultate this breathsound? (Refer to
audio.)
1. Over the trachea
2. Over the peripheral lung fields 3.Posteriorly at T4 medial to the scapula
4.Between the first and second intercostal spaces at the sternal borderanteriorly: 2
(Rationale:
Breath sounds are noises resulting from the transmission of vibrations produced by the
movement of air in the respiratory passages. Normal breath sounds includebronchovesicular
sounds, vesicular breath sounds, and bronchial breath sounds.
The sounds that the nurse hears are vesicular breath sounds. Vesicular breath sounds normally
are heard over the lesser bronchi, bronchioles, and lobes (periph-eral lung fields). These
sounds are soft and low pitched and resemble a sighing or gentle rustling, and the inspiration
, phase is longer than the expiration phase. Bron-chovesicular breath sounds normally are heard
over the first and second intercostalspaces at the sternal border anteriorly and at T4 medial to
the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and
vesicular breathsounds and are moderately pitched with a medium intensity. The inspiration
and expiration phases are equal. Bronchial breath sounds are loud, high-pitched soundsthat
resemble air blowing through a hollow pipe. The expiration phase is louder and longer than
the inspiration phase, and there is a distinct pause between the inspiration and expiration
phase. Bronchial breath sounds are heard normally overthe manubrium.)
7. The nurse is preparing a plan of care for the client who will be returning from
surgery following a right lung wedge resection. Included in the plan of care isthat in the
postoperative period, the nurse should avoid which positioning?
1.In low-Fowler's 2.In semi-Fowler's 3.On the left side 4.On the right side: 4(Rationale:
Following a wedge resection, the client should not be placed on the operative side. Lying on
the operative side hinders expansion of remaining lung tissue and
may accentuate perfusion of poorly ventilated tissue. This further impedes normalgas
exchange. In addition, complete lateral turning may be contraindicated. The surgeon's
prescriptions for positioning after this surgical procedure are always followed.)
8. The nurse is caring for an older client who is on bed rest. The nurse planswhich intervention
to prevent respiratory complications?
1.Decreasing oral fluid intake 2.Monitoring the vital signs every shift
3. Changing the client's position every 2 hours
4. Instructing the client to bear down every hour and to hold his or her breath: 3(Rationale:
Frequent position changes help mobilize lung secretions and prevent pooling. Thisis the only
intervention identified in the options that will prevent respiratory compli- cations. The nurse
should encourage fluid intake to thin secretions and thus enablethe client to expectorate more
easily. It is important to encourage coughing and deep breathing to mobilize lung secretions.
The nurse should assess the client's vitalsigns every 4 hours to identify an elevated temperature,
which may suggest infection.The client should be instructed to avoid the Valsalva maneuver or
any activity that involves holding the breath.)
9. The nurse notes that a hospitalized client has experienced a positive reac-tion to the
tuberculin skin test. Which action by the nurse is priority?
1. Report the findings.
