RESPIRATORY NCLEX Questions I and 2 - 300
Questions and Answers With Rationale
Set I - Qns 1-50
1. A nurse is assessing a client with a history of emphysema. Which of the following clinical
manifestations should the nurse expect to find?
A. Increased anterior-posterior chest diameter
B. Prolonged inspiration
C. Increased respiratory rate
D. Cyanotic mucous membranes
Answer: A
Rationale: A barrel chest (increased anterior-posterior diameter) is a classic sign of
emphysema due to hyperinflation of the lungs and air trapping. Prolonged expiration (not
inspiration) is also a key feature. Clients with emphysema are often described as "pink
puffers," meaning they maintain adequate oxygenation until late in the disease, so cyanosis
is less common than in chronic bronchitis.
2. A client is admitted with an acute asthma attack. Which of the following medications
should the nurse anticipate administering first?
A. Fluticasone (Flovent)
B. Albuterol (Proventil)
C. Montelukast (Singulair)
D. Prednisone
Answer: B
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) used as a rescue medication for
acute bronchospasm. It provides rapid relief by bronchodilating the airways. Fluticasone is
an inhaled corticosteroid (ICS) for long-term control. Montelukast is a leukotriene modifier
for long-term control. Prednisone is a systemic corticosteroid, which is also used but is not
the first-line, fastest-acting rescue medication.
3. The nurse is reviewing an arterial blood gas (ABG) result for a client with pneumonia: pH
7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L. How should the nurse interpret this result?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A
Rationale: The pH is low (acidotic), and the PaCO2 is high (acidotic). The HCO3 is within the
normal range (22-26 mEq/L). When the pH and PaCO2 move in opposite directions (low pH,
high CO2), the primary problem is respiratory. Therefore, this is uncompensated respiratory
acidosis.
,4. A nurse is teaching a client how to use a metered-dose inhaler (MDI) with a spacer. Which
of the following instructions should the nurse include?
A. "Inhale quickly and forcefully through the spacer."
B. "Wait 5 minutes between puffs of the same medication."
C. "Rinse your mouth with water after using a steroid inhaler."
D. "Hold your breath for 2 seconds after inhaling."
Answer: C
Rationale: Rinsing the mouth after using an inhaled corticosteroid is crucial to prevent oral
candidiasis (thrush). Inhalation should be slow and deep, not quick and forceful. The client
should wait 1-2 minutes between puffs of the same medication. The breath should be held
for 10 seconds, if possible, to allow for medication deposition.
5. A client with a chest tube following a thoracotomy has continuous bubbling in the water
seal chamber. What is the nurse's priority action?
A. Clamp the chest tube immediately.
B. Notify the physician.
C. Check the connections for an air leak.
D. Document the finding as normal.
Answer: C
Rationale: Continuous (or intermittent) bubbling in the water seal chamber indicates an air
leak. The nurse's first action should be to check the entire system, from the client's chest
tube insertion site to the drainage system, for loose connections. Clamping the tube can be
dangerous if a pneumothorax is present.
6. Which of the following clients is at highest risk for developing a pulmonary embolism
(PE)?
A. A 30-year-old client with asthma.
B. A 45-year-old client who had a knee replacement 3 days ago.
C. A 60-year-old client with emphysema.
D. A 25-year-old client with a fractured arm.
Answer: B
Rationale: Venous stasis, endothelial injury, and hypercoagulability (Virchow's triad) are the
primary risk factors for a PE. Major orthopedic surgery, such as a knee replacement,
significantly increases the risk due to venous stasis and surgical trauma. The other clients
have respiratory or minor injury issues but do not have the same high risk for clot formation.
7. A nurse is caring for a client with a tracheostomy. Which of the following actions is
essential when performing tracheostomy care?
A. Use sterile technique for suctioning.
B. Clean the stoma with hydrogen peroxide.
C. Change the tracheostomy ties daily.
D. Suction for at least 30 seconds to ensure clearing.
,Answer: A
Rationale: Suctioning the tracheostomy is a sterile procedure to prevent introducing bacteria
into the lower respiratory tract. The stoma should be cleaned with sterile saline or a
prescribed solution, not hydrogen peroxide, which can damage tissue. Ties are changed as
needed, usually not daily unless soiled. Suctioning should be limited to 10-15 seconds to
prevent hypoxia.
8. A client is prescribed oxygen at 2 L/min via nasal cannula. The client has a history of
chronic obstructive pulmonary disease (COPD). What is the rationale for this low-flow
oxygen prescription?
A. To prevent oxygen toxicity.
B. To avoid suppressing the hypoxic drive.
C. To increase the respiratory rate.
D. To prevent absorption atelectasis.
Answer: B
Rationale: Clients with severe COPD may rely on a low PaO2 (hypoxic drive) to stimulate
respiration, rather than the normal high PaCO2 drive. Administering high-flow oxygen can
blunt this drive, leading to hypoventilation and respiratory failure. Therefore, low-flow
oxygen is prescribed.
9. The nurse is preparing to administer a tuberculin skin test (Mantoux). Which of the
following sites is the correct location for injection?
A. Deltoid muscle
B. Vastus lateralis
C. Inner forearm
D. Upper back
Answer: C
Rationale: The Mantoux test is an intradermal injection. The standard site is the inner aspect
of the forearm, about 2-4 inches below the antecubital space. It is not given intramuscularly
(deltoid, vastus lateralis) or subcutaneously.
10. A client is admitted with a diagnosis of pneumonia. Which of the following assessment
findings would be most concerning to the nurse?
A. Respiratory rate of 24 breaths/min
B. Productive cough with green sputum
C. Confusion and restlessness
D. Temperature of 101.2°F (38.4°C)
Answer: C
Rationale: Confusion and restlessness in a client with pneumonia can indicate hypoxia
(decreased oxygen to the brain), which is a sign of deteriorating respiratory status and a
medical emergency. The other findings are common and expected in pneumonia but are less
immediately life-threatening.
, 11. A nurse is teaching a client about the use of a peak flow meter. What is the primary
purpose of this device?
A. To diagnose asthma.
B. To measure the effectiveness of bronchodilators.
C. To monitor for changes in lung function before an asthma attack.
D. To deliver medication directly to the lungs.
Answer: C
Rationale: A peak flow meter measures the peak expiratory flow rate (PEFR). Its primary
purpose is to monitor lung function at home and detect subtle decreases in airflow that may
indicate an impending asthma attack, allowing for early intervention. It is not used for
diagnosis or to deliver medication.
12. A client is receiving mechanical ventilation. The high-pressure alarm sounds. Which of
the following is the most likely cause?
A. A leak in the ventilator circuit
B. The client is biting the endotracheal tube
C. The client is disconnected from the ventilator
D. A decrease in the client's respiratory rate
Answer: B
Rationale: A high-pressure alarm indicates increased resistance to airflow. Common causes
include coughing, biting the ET tube, secretions in the airway, or kinking of the tubing. A leak
or disconnection would trigger a low-pressure (or low-volume) alarm.
13. A nurse is assessing a client who has just had a chest tube inserted for a pneumothorax.
Which finding indicates the system is functioning correctly?
A. Continuous bubbling in the suction control chamber.
B. Fluctuation (tidaling) of the fluid level in the water seal chamber.
C. No bubbling in the water seal chamber.
D. The drainage in the collection chamber is dark red.
Answer: B
Rationale: Tidaling (the fluid level rising with inspiration and falling with expiration) in the
water seal chamber indicates that the system is patent and in communication with the
pleural space. Continuous bubbling in the suction control chamber is expected if suction is
ordered. The absence of bubbling in the water seal is normal if there is no air leak.
14. Which of the following positions is best for a client experiencing an acute asthma attack?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Left lateral
Answer: B
Questions and Answers With Rationale
Set I - Qns 1-50
1. A nurse is assessing a client with a history of emphysema. Which of the following clinical
manifestations should the nurse expect to find?
A. Increased anterior-posterior chest diameter
B. Prolonged inspiration
C. Increased respiratory rate
D. Cyanotic mucous membranes
Answer: A
Rationale: A barrel chest (increased anterior-posterior diameter) is a classic sign of
emphysema due to hyperinflation of the lungs and air trapping. Prolonged expiration (not
inspiration) is also a key feature. Clients with emphysema are often described as "pink
puffers," meaning they maintain adequate oxygenation until late in the disease, so cyanosis
is less common than in chronic bronchitis.
2. A client is admitted with an acute asthma attack. Which of the following medications
should the nurse anticipate administering first?
A. Fluticasone (Flovent)
B. Albuterol (Proventil)
C. Montelukast (Singulair)
D. Prednisone
Answer: B
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) used as a rescue medication for
acute bronchospasm. It provides rapid relief by bronchodilating the airways. Fluticasone is
an inhaled corticosteroid (ICS) for long-term control. Montelukast is a leukotriene modifier
for long-term control. Prednisone is a systemic corticosteroid, which is also used but is not
the first-line, fastest-acting rescue medication.
3. The nurse is reviewing an arterial blood gas (ABG) result for a client with pneumonia: pH
7.30, PaCO2 50 mm Hg, HCO3 24 mEq/L. How should the nurse interpret this result?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A
Rationale: The pH is low (acidotic), and the PaCO2 is high (acidotic). The HCO3 is within the
normal range (22-26 mEq/L). When the pH and PaCO2 move in opposite directions (low pH,
high CO2), the primary problem is respiratory. Therefore, this is uncompensated respiratory
acidosis.
,4. A nurse is teaching a client how to use a metered-dose inhaler (MDI) with a spacer. Which
of the following instructions should the nurse include?
A. "Inhale quickly and forcefully through the spacer."
B. "Wait 5 minutes between puffs of the same medication."
C. "Rinse your mouth with water after using a steroid inhaler."
D. "Hold your breath for 2 seconds after inhaling."
Answer: C
Rationale: Rinsing the mouth after using an inhaled corticosteroid is crucial to prevent oral
candidiasis (thrush). Inhalation should be slow and deep, not quick and forceful. The client
should wait 1-2 minutes between puffs of the same medication. The breath should be held
for 10 seconds, if possible, to allow for medication deposition.
5. A client with a chest tube following a thoracotomy has continuous bubbling in the water
seal chamber. What is the nurse's priority action?
A. Clamp the chest tube immediately.
B. Notify the physician.
C. Check the connections for an air leak.
D. Document the finding as normal.
Answer: C
Rationale: Continuous (or intermittent) bubbling in the water seal chamber indicates an air
leak. The nurse's first action should be to check the entire system, from the client's chest
tube insertion site to the drainage system, for loose connections. Clamping the tube can be
dangerous if a pneumothorax is present.
6. Which of the following clients is at highest risk for developing a pulmonary embolism
(PE)?
A. A 30-year-old client with asthma.
B. A 45-year-old client who had a knee replacement 3 days ago.
C. A 60-year-old client with emphysema.
D. A 25-year-old client with a fractured arm.
Answer: B
Rationale: Venous stasis, endothelial injury, and hypercoagulability (Virchow's triad) are the
primary risk factors for a PE. Major orthopedic surgery, such as a knee replacement,
significantly increases the risk due to venous stasis and surgical trauma. The other clients
have respiratory or minor injury issues but do not have the same high risk for clot formation.
7. A nurse is caring for a client with a tracheostomy. Which of the following actions is
essential when performing tracheostomy care?
A. Use sterile technique for suctioning.
B. Clean the stoma with hydrogen peroxide.
C. Change the tracheostomy ties daily.
D. Suction for at least 30 seconds to ensure clearing.
,Answer: A
Rationale: Suctioning the tracheostomy is a sterile procedure to prevent introducing bacteria
into the lower respiratory tract. The stoma should be cleaned with sterile saline or a
prescribed solution, not hydrogen peroxide, which can damage tissue. Ties are changed as
needed, usually not daily unless soiled. Suctioning should be limited to 10-15 seconds to
prevent hypoxia.
8. A client is prescribed oxygen at 2 L/min via nasal cannula. The client has a history of
chronic obstructive pulmonary disease (COPD). What is the rationale for this low-flow
oxygen prescription?
A. To prevent oxygen toxicity.
B. To avoid suppressing the hypoxic drive.
C. To increase the respiratory rate.
D. To prevent absorption atelectasis.
Answer: B
Rationale: Clients with severe COPD may rely on a low PaO2 (hypoxic drive) to stimulate
respiration, rather than the normal high PaCO2 drive. Administering high-flow oxygen can
blunt this drive, leading to hypoventilation and respiratory failure. Therefore, low-flow
oxygen is prescribed.
9. The nurse is preparing to administer a tuberculin skin test (Mantoux). Which of the
following sites is the correct location for injection?
A. Deltoid muscle
B. Vastus lateralis
C. Inner forearm
D. Upper back
Answer: C
Rationale: The Mantoux test is an intradermal injection. The standard site is the inner aspect
of the forearm, about 2-4 inches below the antecubital space. It is not given intramuscularly
(deltoid, vastus lateralis) or subcutaneously.
10. A client is admitted with a diagnosis of pneumonia. Which of the following assessment
findings would be most concerning to the nurse?
A. Respiratory rate of 24 breaths/min
B. Productive cough with green sputum
C. Confusion and restlessness
D. Temperature of 101.2°F (38.4°C)
Answer: C
Rationale: Confusion and restlessness in a client with pneumonia can indicate hypoxia
(decreased oxygen to the brain), which is a sign of deteriorating respiratory status and a
medical emergency. The other findings are common and expected in pneumonia but are less
immediately life-threatening.
, 11. A nurse is teaching a client about the use of a peak flow meter. What is the primary
purpose of this device?
A. To diagnose asthma.
B. To measure the effectiveness of bronchodilators.
C. To monitor for changes in lung function before an asthma attack.
D. To deliver medication directly to the lungs.
Answer: C
Rationale: A peak flow meter measures the peak expiratory flow rate (PEFR). Its primary
purpose is to monitor lung function at home and detect subtle decreases in airflow that may
indicate an impending asthma attack, allowing for early intervention. It is not used for
diagnosis or to deliver medication.
12. A client is receiving mechanical ventilation. The high-pressure alarm sounds. Which of
the following is the most likely cause?
A. A leak in the ventilator circuit
B. The client is biting the endotracheal tube
C. The client is disconnected from the ventilator
D. A decrease in the client's respiratory rate
Answer: B
Rationale: A high-pressure alarm indicates increased resistance to airflow. Common causes
include coughing, biting the ET tube, secretions in the airway, or kinking of the tubing. A leak
or disconnection would trigger a low-pressure (or low-volume) alarm.
13. A nurse is assessing a client who has just had a chest tube inserted for a pneumothorax.
Which finding indicates the system is functioning correctly?
A. Continuous bubbling in the suction control chamber.
B. Fluctuation (tidaling) of the fluid level in the water seal chamber.
C. No bubbling in the water seal chamber.
D. The drainage in the collection chamber is dark red.
Answer: B
Rationale: Tidaling (the fluid level rising with inspiration and falling with expiration) in the
water seal chamber indicates that the system is patent and in communication with the
pleural space. Continuous bubbling in the suction control chamber is expected if suction is
ordered. The absence of bubbling in the water seal is normal if there is no air leak.
14. Which of the following positions is best for a client experiencing an acute asthma attack?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Left lateral
Answer: B
