Medical Surgical Nursing Respiratory Exam Question and Answers
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items
should the nurse keep easily accessible for the client?
A. Extra drainage system
B. Suture removal kit
C. Container of sterile water
D. Nonadherent pads
Answer: C. Container of sterile water
Rationale: The nurse should have a container of sterile water in a location that is easily accessible for
this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing
becomes disconnected in order to prevent a pneumothorax.
A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the
following findings should the nurse notify the provider?
A. Fluctuation of drainage in the tubing with inspiration
B. Continuous bubbling in the water seal chamber
C. Drainage of 75 mL in the first hour after surgery
D. Several small, dark-red blood clots in the tubing
Answer: B. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification
of the provider. The nurse should check the system for external, correctable leaks while she is waiting
for instructions from the provider.
A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which
of the following actions should the nurse take?
A. Use clean technique when suctioning the client's endotracheal tube.
B. Use a rotating motion when removing the suction catheter.
C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube.
D. Suction the client's endotracheal tube every 2 hr.
, Answer: B. Use a rotating motion when removing the suction catheter.
Rationale: The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue
trauma.
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in
which of the following positions to promote effective breathing?
A. Lateral position with a pillow at the back and over the chest to support the arm
B. High-Fowler's position with the arms supported on the over-bed table
C. Semi-Fowler's position with pillows supporting both arms
D. Supine position with the head of the bed elevated to 15°
Answer: B. High-Fowler's position with the arms supported on the over-bed table
Rationale: The nurse should place the client in a position that allows for greater expansion of the chest,
such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort
on the over-bed table.
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery
devices should the nurse use to provide the client with the highest level of oxygen?
A. Nasal cannula
B. Nonrebreather mask
C. Simple face mask
D. Partial rebreather mask
Answer: B. Nonrebreather mask
Rationale: The nurse should use a non-rebreather mask for a client in respiratory distress to provide the
highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains
the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation
ports with flaps that prevent room air from entering the mask. This device delivers greater than 90%
FiO2.
A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions
should the nurse implement?
A. Airborne
B. Neutropenic
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items
should the nurse keep easily accessible for the client?
A. Extra drainage system
B. Suture removal kit
C. Container of sterile water
D. Nonadherent pads
Answer: C. Container of sterile water
Rationale: The nurse should have a container of sterile water in a location that is easily accessible for
this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing
becomes disconnected in order to prevent a pneumothorax.
A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the
following findings should the nurse notify the provider?
A. Fluctuation of drainage in the tubing with inspiration
B. Continuous bubbling in the water seal chamber
C. Drainage of 75 mL in the first hour after surgery
D. Several small, dark-red blood clots in the tubing
Answer: B. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification
of the provider. The nurse should check the system for external, correctable leaks while she is waiting
for instructions from the provider.
A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which
of the following actions should the nurse take?
A. Use clean technique when suctioning the client's endotracheal tube.
B. Use a rotating motion when removing the suction catheter.
C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube.
D. Suction the client's endotracheal tube every 2 hr.
, Answer: B. Use a rotating motion when removing the suction catheter.
Rationale: The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue
trauma.
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in
which of the following positions to promote effective breathing?
A. Lateral position with a pillow at the back and over the chest to support the arm
B. High-Fowler's position with the arms supported on the over-bed table
C. Semi-Fowler's position with pillows supporting both arms
D. Supine position with the head of the bed elevated to 15°
Answer: B. High-Fowler's position with the arms supported on the over-bed table
Rationale: The nurse should place the client in a position that allows for greater expansion of the chest,
such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort
on the over-bed table.
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery
devices should the nurse use to provide the client with the highest level of oxygen?
A. Nasal cannula
B. Nonrebreather mask
C. Simple face mask
D. Partial rebreather mask
Answer: B. Nonrebreather mask
Rationale: The nurse should use a non-rebreather mask for a client in respiratory distress to provide the
highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains
the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation
ports with flaps that prevent room air from entering the mask. This device delivers greater than 90%
FiO2.
A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions
should the nurse implement?
A. Airborne
B. Neutropenic
