NCLEX ON RESPIRATORY SYSTEM TEST BANK
NEWEST EXAM 69 QUESTIONS WITH CORRECT
VERIFIED ANSWERS AND RATIONALES GRADED
A+ 2024|REAL EXAM!!!
The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally
disconnected, what should the nurse plan to do?
a. Place the end of the chest tube in a container of sterile saline.
b. Apply an occlusive dressing and notify the physician.
c. Clamp the chest tube immediately.
d. Secure the chest tube with tape. - ANSWERS -qAnswer A. If a chest drainage system is disconnected,
the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air
from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should
apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The
nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax.
The nurse should tape the chest tube securely to prevent it from being disconnected, rather than
taping it after it has been disconnected.
A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client
closely for complications. What is the most common complication of influenza?
a. Septicemia
b. Pneumonia
c. Meningitis
d. Pulmonary edema - ANSWERS -Answer B. Pneumonia is the most common complication of
influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial
infection. Other complications of influenza include myositis, exacerbation of chronic obstructive
pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and
encephalitis are rare complications of influenza. Although septicemia may arise when any infection
becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't
associated with influenza.
,A female client has a tracheostomy but doesn't require continuous mechanical ventilation. When
weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube
for:
a. 15 to 60 seconds.
b. 5 to 20 minutes.
c. 30 to 40 minutes.
d. 45 to 60 minutes. - ANSWERS -Answer B. Initially, the nurse should plug the opening in the
tracheostomy tube for 5 to 20 minutes, and then gradually lengthen this interval according to the
client's respiratory status. A client who doesn't require continuous mechanical ventilation already is
breathing without assistance, at least for short periods; therefore, plugging the opening of the tube
for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the
procedure. Plugging the opening for more than 20 minutes would increase the risk of acute
respiratory distress because the client requires an adjustment period to start breathing normally
Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the
client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These
signs are associated with which condition?
a. Hypoxia
b. Delirium
c. Hyperventilation
d. Semiconsciousness - ANSWERS -Answer A. As the respiratory center in the brain becomes
depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate.
Delirium is a state of mental confusion characterized by disorientation to time and place.
Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is
marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of
impaired consciousness characterized by limited motor and verbal responses and decreased
orientation.
A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar
ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
a. pH, 5.0; PaCO2 30 mm Hg
b. pH, 7.40; PaCO2 35 mm Hg
, c. pH, 7.35; PaCO2 40 mm Hg
d. pH, 7.25; PaCO2 50 mm Hg - ANSWERS -Answer D. In respiratory acidosis, ABG analysis reveals an
arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg.
Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory
acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B
and C represent normal ABG values, reflecting normal gas exchange in the lungs.
A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control
inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as
prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone
abruptly may experience:
a. hyperglycemia and glycosuria.
b. acute adrenocortical insufficiency.
c. GI bleeding.
d. restlessness and seizures. - ANSWERS -Answer B. Administration of a corticosteroid such as
prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to
normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol
level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI
bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its
sudden cessation.
A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary
disease. Which nursing diagnosis is most important for this client?
a. Activity intolerance related to fatigue
b. Anxiety related to actual threat to health status
c. Risk for infection related to retained secretions
d. Impaired gas exchange related to airflow obstruction - ANSWERS -Answer D. A patent airway and an
adequate breathing pattern are the top priority for any client, making impaired gas exchange related to
airflow obstruction the most important nursing diagnosis. The other options also may apply to this client
but are less important.
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen
saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?
NEWEST EXAM 69 QUESTIONS WITH CORRECT
VERIFIED ANSWERS AND RATIONALES GRADED
A+ 2024|REAL EXAM!!!
The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally
disconnected, what should the nurse plan to do?
a. Place the end of the chest tube in a container of sterile saline.
b. Apply an occlusive dressing and notify the physician.
c. Clamp the chest tube immediately.
d. Secure the chest tube with tape. - ANSWERS -qAnswer A. If a chest drainage system is disconnected,
the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air
from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should
apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The
nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax.
The nurse should tape the chest tube securely to prevent it from being disconnected, rather than
taping it after it has been disconnected.
A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client
closely for complications. What is the most common complication of influenza?
a. Septicemia
b. Pneumonia
c. Meningitis
d. Pulmonary edema - ANSWERS -Answer B. Pneumonia is the most common complication of
influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial
infection. Other complications of influenza include myositis, exacerbation of chronic obstructive
pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and
encephalitis are rare complications of influenza. Although septicemia may arise when any infection
becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't
associated with influenza.
,A female client has a tracheostomy but doesn't require continuous mechanical ventilation. When
weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube
for:
a. 15 to 60 seconds.
b. 5 to 20 minutes.
c. 30 to 40 minutes.
d. 45 to 60 minutes. - ANSWERS -Answer B. Initially, the nurse should plug the opening in the
tracheostomy tube for 5 to 20 minutes, and then gradually lengthen this interval according to the
client's respiratory status. A client who doesn't require continuous mechanical ventilation already is
breathing without assistance, at least for short periods; therefore, plugging the opening of the tube
for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the
procedure. Plugging the opening for more than 20 minutes would increase the risk of acute
respiratory distress because the client requires an adjustment period to start breathing normally
Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the
client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These
signs are associated with which condition?
a. Hypoxia
b. Delirium
c. Hyperventilation
d. Semiconsciousness - ANSWERS -Answer A. As the respiratory center in the brain becomes
depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate.
Delirium is a state of mental confusion characterized by disorientation to time and place.
Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is
marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of
impaired consciousness characterized by limited motor and verbal responses and decreased
orientation.
A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar
ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
a. pH, 5.0; PaCO2 30 mm Hg
b. pH, 7.40; PaCO2 35 mm Hg
, c. pH, 7.35; PaCO2 40 mm Hg
d. pH, 7.25; PaCO2 50 mm Hg - ANSWERS -Answer D. In respiratory acidosis, ABG analysis reveals an
arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg.
Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory
acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B
and C represent normal ABG values, reflecting normal gas exchange in the lungs.
A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control
inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as
prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone
abruptly may experience:
a. hyperglycemia and glycosuria.
b. acute adrenocortical insufficiency.
c. GI bleeding.
d. restlessness and seizures. - ANSWERS -Answer B. Administration of a corticosteroid such as
prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to
normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol
level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI
bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its
sudden cessation.
A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary
disease. Which nursing diagnosis is most important for this client?
a. Activity intolerance related to fatigue
b. Anxiety related to actual threat to health status
c. Risk for infection related to retained secretions
d. Impaired gas exchange related to airflow obstruction - ANSWERS -Answer D. A patent airway and an
adequate breathing pattern are the top priority for any client, making impaired gas exchange related to
airflow obstruction the most important nursing diagnosis. The other options also may apply to this client
but are less important.
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen
saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?
