NCLEX Q&A RESPIRATORY STUDY GUIDE 2025 | GRADE A | 100% CORRECT -THE ULTIMATE GUIDE FOR YR. (2026/2027)

NCLEX Q&A RESPIRATORY STUDY GUIDE 2025 | GRADE A | 100% CORRECT -THE ULTIMATE GUIDE FOR YR. (2026/2027) A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client? 1. "You'll wear a lead shield to partially protect your organs from harm." 2. "The amount of x-ray exposure is not sufficient to cause DNA damage." "The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation." 3. "The test isn't harmful at all. The most frustrating part is the long wait in radiology." 4. The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? 1. Edema 2. Dyspnea 3. Frothy sputum 4. Diminished breath sounds The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water seal chamber has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tube may be obstructed. The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement made by the client indicates a need for further teaching? 1. "I should avoid heavy lifting for at least 4 to 6 weeks." 2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider." The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? 1. Inflate the cuff on the tracheostomy tube. 2. Deflate the cuff on the tracheostomy tube. 3. Maintain the head of the bed in low Fowler's position. 4. Place the tray in a comfortable position in front of the client. Rationale: Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler's position could lead to aspiration. The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures? 1. "I should restrict my fluid intake for 2 weeks." 2. "I should perform arm exercises 2 or 3 times a day." 3. "If I experience any soreness in my chest or shoulder, I should notify the health care provider." 4. "If I experience any numbness or altered sensation around the incision, I should contact the health care provider." Rationale: The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the health care provider if these symptoms occur. A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse determines that the pain is most likely of a respiratory origin if the client makes which statement about the pain? 1. "It hurts more when I breathe in." 2. "I have never had this pain before." 3. "It hurts on the left side of my chest." 4. "The pain is about a 6 on a scale of 1 to 10." A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? 1. Administration of plasma expanders, low-flow oxygen, and suctioning 2. Administration of bronchodilators, intubation, and mechanical ventilation 3. Administration of oxygen, intubation, and mechanical ventilation with positive end- expiratory pressure 4. Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action? 1. Continue to monitor. 2. Document the findings. 3. Change the chest tube drainage system. 4. Perform a focused respiratory assessment. The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1. Muscle weakness in the arms and legs 2. A temperature of 98.6°F (37°C), decreased from 99.0°F (37.2°C) 3. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 4. A heart rate of 80 beats/minute, decreased from 85 beats/minute The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate? 1. Inform the HCP. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe. 33 The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? 1. Tape the ET tube in place, and note the centimeter marking at the lip line. 2. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 3.