NCLEX - RespiratoryQuestions and Answers with
Rationales 2025 100% PASS
A client is undergoing a complete physical examination as a requirement for college. When checking the
client's respiratory status, the nurse observes respiratory excursion to help assess:
a) lung vibrations
b) vocal sounds
c) breath sounds
d) chest movements - ✔✔✔d) chest movements
What is the normal pH range for arterial blood?
a) 7 to 7.49
b) 7.35 to 7.45
c) 7.50 to 7.60
d) 7.55 to 7.65 - ✔✔✔b) 7.35 to 7.45
A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin
skin test converter. Management of her care would include:
a) scheduling her for annual tuberculin skin testing.
b) placing her in quarantine until sputum cultures are negative.
c) gathering a list of persons with whom she has had recent contact.
d) advising her to begin prophylactic therapy with isoniazid (INH). - ✔✔✔d) advising her to begin
prophylactic therapy with isoniazid (INH).
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should
give which instruction to the client and family?
,a) "Clean the tracheostomy tube with alcohol and water."
b) "Family members should continue to talk to the client."
c) "Oral intake of fluids should be limited for 1 week only."
d) "Limit the amount of protein in the diet." - ✔✔✔b) "Family members should continue to talk to the
client."
The physician determines that a client has been exposed to someone with tuberculosis. The nurse
expects the physician to order which of the following?
a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years
b) Isolation until 24 hours after antitubercular therapy begins
c) Nothing, until signs of active disease arise
d) Daily doses of isoniazid, 300 mg for 6 months to 1 year - ✔✔✔d) Daily doses of isoniazid, 300 mg for 6
months to 1 year
The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a
bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the
client is using the spirometer properly. During each waking hour, the client should perform a minimum
of how many sustained, voluntary inflation maneuvers?
a) One to two
b) Three to four
c) Five to seven
d) Eight to ten - ✔✔✔d) Eight to ten
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure
alarm on the ventilator sounds, what should the nurse do?
a) Check for an apical pulse.
b) Suction the client's artificial airway.
,c) Increase the oxygen percentage.
d) Ventilate the client with a handheld mechanical ventilator. - ✔✔✔b) Suction the client's artificial
airway.
A 29-year-old client with severe shortness of breath comes to the emergency department. He tells the
emergency department staff that he recently traveled to China for business. Based on his travel history
and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation
precautions should the staff institute?
a) Droplet precautions
b) Airborne and contact precautions
c) Contact and droplet precautions
d) Contact precautions - ✔✔✔b) Airborne and contact precautions
The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest
bacterial pneumonia?
a) Nonproductive cough and normal temperature
b) Sore throat and abdominal pain
c) Hemoptysis and dysuria
d) Dyspnea and wheezing - ✔✔✔d) Dyspnea and wheezing
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must
receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks
the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid
therapy?
a) 3 to 5 days
b) 1 to 3 weeks
c) 2 to 4 months
d) 6 to 12 months - ✔✔✔d) 6 to 12 months
, The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring
for a client with a tracheostomy is:
a) helping him communicate.
b) keeping his airway patent.
c) encouraging him to perform activities of daily living.
d) preventing him from developing an infection. - ✔✔✔b) keeping his airway patent.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by
the nurse takes the highest priority?
a) Monitor vital signs and oxygen saturation every 15 to 30 minutes.
b) Suction the client as needed to obtain a sputum specimen for culture and sensitivity.
c) Assess intake and output and maintain adequate hydration.
d) Reassure the client that intubation and mechanical ventilation will be temporary. - ✔✔✔a) Monitor
vital signs and oxygen saturation every 15 to 30 minutes.
A client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50
ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the
nurse to change the dosage to 0.45 mg/kg/hour. The nurse should:
a) question the order because the dosage is too low.
b) question the order because the dosage is too high.
c) set the pump at 45 ml/hour.
d) stop the infusion and have the laboratory repeat the theophylline measurement. - ✔✔✔a) question
the order because the dosage is too low.
A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary
embolism. Which nursing diagnosis takes priority with this client?
Rationales 2025 100% PASS
A client is undergoing a complete physical examination as a requirement for college. When checking the
client's respiratory status, the nurse observes respiratory excursion to help assess:
a) lung vibrations
b) vocal sounds
c) breath sounds
d) chest movements - ✔✔✔d) chest movements
What is the normal pH range for arterial blood?
a) 7 to 7.49
b) 7.35 to 7.45
c) 7.50 to 7.60
d) 7.55 to 7.65 - ✔✔✔b) 7.35 to 7.45
A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin
skin test converter. Management of her care would include:
a) scheduling her for annual tuberculin skin testing.
b) placing her in quarantine until sputum cultures are negative.
c) gathering a list of persons with whom she has had recent contact.
d) advising her to begin prophylactic therapy with isoniazid (INH). - ✔✔✔d) advising her to begin
prophylactic therapy with isoniazid (INH).
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should
give which instruction to the client and family?
,a) "Clean the tracheostomy tube with alcohol and water."
b) "Family members should continue to talk to the client."
c) "Oral intake of fluids should be limited for 1 week only."
d) "Limit the amount of protein in the diet." - ✔✔✔b) "Family members should continue to talk to the
client."
The physician determines that a client has been exposed to someone with tuberculosis. The nurse
expects the physician to order which of the following?
a) Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years
b) Isolation until 24 hours after antitubercular therapy begins
c) Nothing, until signs of active disease arise
d) Daily doses of isoniazid, 300 mg for 6 months to 1 year - ✔✔✔d) Daily doses of isoniazid, 300 mg for 6
months to 1 year
The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a
bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the
client is using the spirometer properly. During each waking hour, the client should perform a minimum
of how many sustained, voluntary inflation maneuvers?
a) One to two
b) Three to four
c) Five to seven
d) Eight to ten - ✔✔✔d) Eight to ten
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure
alarm on the ventilator sounds, what should the nurse do?
a) Check for an apical pulse.
b) Suction the client's artificial airway.
,c) Increase the oxygen percentage.
d) Ventilate the client with a handheld mechanical ventilator. - ✔✔✔b) Suction the client's artificial
airway.
A 29-year-old client with severe shortness of breath comes to the emergency department. He tells the
emergency department staff that he recently traveled to China for business. Based on his travel history
and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation
precautions should the staff institute?
a) Droplet precautions
b) Airborne and contact precautions
c) Contact and droplet precautions
d) Contact precautions - ✔✔✔b) Airborne and contact precautions
The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest
bacterial pneumonia?
a) Nonproductive cough and normal temperature
b) Sore throat and abdominal pain
c) Hemoptysis and dysuria
d) Dyspnea and wheezing - ✔✔✔d) Dyspnea and wheezing
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must
receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks
the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid
therapy?
a) 3 to 5 days
b) 1 to 3 weeks
c) 2 to 4 months
d) 6 to 12 months - ✔✔✔d) 6 to 12 months
, The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring
for a client with a tracheostomy is:
a) helping him communicate.
b) keeping his airway patent.
c) encouraging him to perform activities of daily living.
d) preventing him from developing an infection. - ✔✔✔b) keeping his airway patent.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by
the nurse takes the highest priority?
a) Monitor vital signs and oxygen saturation every 15 to 30 minutes.
b) Suction the client as needed to obtain a sputum specimen for culture and sensitivity.
c) Assess intake and output and maintain adequate hydration.
d) Reassure the client that intubation and mechanical ventilation will be temporary. - ✔✔✔a) Monitor
vital signs and oxygen saturation every 15 to 30 minutes.
A client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophyllin) (400 mg in 500 ml) at 50
ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the
nurse to change the dosage to 0.45 mg/kg/hour. The nurse should:
a) question the order because the dosage is too low.
b) question the order because the dosage is too high.
c) set the pump at 45 ml/hour.
d) stop the infusion and have the laboratory repeat the theophylline measurement. - ✔✔✔a) question
the order because the dosage is too low.
A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary
embolism. Which nursing diagnosis takes priority with this client?
