Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is providing care to a patient who has a tracheostomy. The loss of
which protective mechanism does the nurse plan to monitor this patient for
during the respiratory assessment process?
1. The ability to cough
2. The filtration and humidification of inspired air
3. A decrease in the oxygen-carrying capacity of the trachea
4. The sneeze reflex initiated by irritants in the nasal passages
2. When conducting a respiratory assessment, the nurse notes a low-pitched sound
that is continuous throughout inspiration. Which does this lung sound indicate
to the nurse?
1. Narrow bronchi
2. Narrow trachea passages
3. Inflamed pleural surfaces
4. Blocked large airway passages
3. The nurse is providing care to a patient admitted with a respiratory disorder.
Which laboratory finding would be most significant?
1. Blood pH 7.32
2. Oxygen saturation 96%
3. Serum sodium 140 mg/dL
4. Hemoglobin level 12 mg/dL
4. The nurse is providing care to a patient diagnosed with chronic obstructive
pulmonary disease (COPD) who is prescribed 24% oxygen at 2 L/min. Which
is the best method for the nurse to use in order to administer oxygen to this
patient?
1. Face mask
2. Venturi mask
3. Nasal cannula
4. Nonrebreather mask
5. The nurse is providing care for a patient admitted with smoke inhalation injury
who is developing acute respiratory distress syndrome (ARDS). Which course
of action regarding oxygen therapy does the nurse anticipate for this patient?
, 1. Oxygen via a facial mask
2. Oxygen via a Venturi mask
3. Oxygen via a nasal cannula
4. Oxygen via mechanical ventilation
6. The nurse is providing care to a patient, diagnosed with asthma, with a
respiratory rate of 28 at rest who is experiencing audible wheezing during
inspiration. Which nursing diagnosis should the nurse use when planning care
for this patient?
1. Activity Intolerance
2. Impaired Tissue Perfusion
3. Ineffective Airway Clearance
4. Ineffective Breathing Pattern
7. The nurse is providing care to a patient who is diagnosed with chronic
obstructive pulmonary disease (COPD). The nurse assesses the patient’s
breathing rate at 32 breaths per minute. The patient is also experiencing
hypertension and fatigue. Which nursing diagnosis is a priority when planning
care for this patient?
1. Anxiety
2. Ineffective Coping
3. Ineffective Breathing Pattern
4. Ineffective Airway Clearance
8. The nurse is providing care to a patient who is diagnosed with chronic
obstructive pulmonary disease (COPD). The patient’s pulse oximetry is 93% on
room air with a current respiratory rate of 35 breaths per minute. The most
recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is
currently febrile with an increased number of white blood cells (WBCs) noted
on the latest complete blood count (CBC). Which prescription does the nurse
question for this patient based on the current data?
1. Antibiotic therapy
2. Nonsteroidal anti-inflammatory therapy
3. Oxygen therapy via nasal cannula at 3-4 L/min
4. Bronchodilators therapy with adrenergic stimulating drugs
9. The nurse is providing care to an infant diagnosed with respiratory syncytial
virus (RSV). The infant is grunting with expiration. Which action by the nurse
is appropriate?
, 1. Limit fluid intake
2. Place the infant in a supine position
3. Perform chest physiotherapy to clear the nasal passages
4. Suction the airway to relieve the current obstruction that is noted
10. Which nursing action determines the accuracy of the detected waveform when
monitoring a patient’s oxygen saturation via oximetry?
1. Using a site with adequate perfusion
2. Ensuring any nail polish is removed
3. Leaving the sensor in place for a minimum of ten seconds
4. Assessing the heart rate and comparing it with the displayed pulse
11. Which did the nurse auscultate when conducting a patient’s respiratory
assessment if wheezing is documented?
1. Snoring sounds
2. Gurgling sounds
3. Low-pitched bubbling
4. High-pitched squeaking
12. Which did the nurse auscultate when conducting a patient’s respiratory
assessment if rhonchi is documented?
1. Snoring sounds
2. Gurgling sounds
3. Low-pitched bubbling
4. High-pitched squeaking
13. Which position should the nurse place a patient prior to performing in-line
suctioning?
1. Prone
2. Supine
3. Fowler’s
4. Semi-Fowler’s
14. When conducting in-line suctioning, which is the maximum amount of time for
each suctioning event?
1. 10 seconds
2. 30 seconds