Respiratory NCLEX Questions and Answers with Solution 2025/2026
The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its
base - (answer)D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced
by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more,
usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse
notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20.
Which of the following nursing diagnosis is most appropriate based upon this assessment? A.
Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C.
Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick
secretions - (answer)A. Hyperthermia related to infectious illness Because the patient has spiked a
temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to
infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20
breaths per minute. There is no evidence of ineffective airway clearance from the information given
because the patient is expectorating sputum.
Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28
C. Presence of greenish sputum D. Basilar crackles - (answer)D. Basilar crackles The presence of
adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This
would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is
retaining secretions.
Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion B. Fine crackles in
all lobes on auscultation C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -
(answer)C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient
with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation
include dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day
if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area. -
(answer)B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the
patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy
the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also
, Respiratory NCLEX Questions and Answers with Solution 2025/2026
helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be
helpful, but does not liquefy the secretions so that they can be removed.
After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
which of the following physician orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient? A. Serum laboratory studies ordered for AM B. Pulmonary function evaluation
C. Orthostatic blood pressures D. Sputum culture and sensitivity - (answer)D. Sputum culture and
sensitivityThe nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory
before administering the cefotetan. It is important that the organisms are correctly identified (by the
culture) before their numbers are affected by the antibiotic; the test will also determine whether the
proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be
unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be
affected by the administration of antibiotics.
The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the
following is the primary reason for the nurse to carefully inspect the chest wall of this patient? A.
Observe for signs of diaphoresis B. Allow time to calm the patient C. Monitor the patient for bilateral
chest expansion D. Evaluate the use of intercostal muscles - (answer)D. Evaluate the use of intercostal
muscles The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory)
muscles, which gives an indication of the degree of respiratory distress experienced by the patient.
A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the
following nursing interventions is most appropriate during admission of this patient? A. Delay any
physical assessment of the patient and review with the family the patient's history of respiratory
problems. B. Perform a comprehensive health history with the patient to review prior respiratory
problems. C. Perform a physical assessment of the respiratory system and ask specific questions related
to this episode of respiratory distress. D. Complete a full physical examination to determine the effect of
the respiratory distress on other body functions. - (answer)C. Perform a physical assessment of the
respiratory system and ask specific questions related to this episode of respiratory distress.Because the
patient is having respiratory difficulty, the nurse should ask specific questions about this episode and
perform a physical assessment of this system. Further history taking and physical examination of other
body systems can proceed once the patient's acute respiratory distress is being managed.
The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician
orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide
to the patient about the procedure? A. This test involves injection of a radioisotope to outline the blood
vessels in the lungs, followed by inhalation of a radioisotope gas. B. This test will use special technology
The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
inspecting: A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its
base - (answer)D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced
by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more,
usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse
notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20.
Which of the following nursing diagnosis is most appropriate based upon this assessment? A.
Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C.
Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick
secretions - (answer)A. Hyperthermia related to infectious illness Because the patient has spiked a
temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to
infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20
breaths per minute. There is no evidence of ineffective airway clearance from the information given
because the patient is expectorating sputum.
Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28
C. Presence of greenish sputum D. Basilar crackles - (answer)D. Basilar crackles The presence of
adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This
would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is
retaining secretions.
Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion B. Fine crackles in
all lobes on auscultation C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -
(answer)C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient
with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation
include dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day
if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area. -
(answer)B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the
patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy
the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also
, Respiratory NCLEX Questions and Answers with Solution 2025/2026
helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be
helpful, but does not liquefy the secretions so that they can be removed.
After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
which of the following physician orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient? A. Serum laboratory studies ordered for AM B. Pulmonary function evaluation
C. Orthostatic blood pressures D. Sputum culture and sensitivity - (answer)D. Sputum culture and
sensitivityThe nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory
before administering the cefotetan. It is important that the organisms are correctly identified (by the
culture) before their numbers are affected by the antibiotic; the test will also determine whether the
proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be
unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be
affected by the administration of antibiotics.
The nurse is assigned to care for a patient who has anxiety and an exacerbation of asthma. Which of the
following is the primary reason for the nurse to carefully inspect the chest wall of this patient? A.
Observe for signs of diaphoresis B. Allow time to calm the patient C. Monitor the patient for bilateral
chest expansion D. Evaluate the use of intercostal muscles - (answer)D. Evaluate the use of intercostal
muscles The nurse physically inspects the chest wall to evaluate the use of intercostal (accessory)
muscles, which gives an indication of the degree of respiratory distress experienced by the patient.
A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the
following nursing interventions is most appropriate during admission of this patient? A. Delay any
physical assessment of the patient and review with the family the patient's history of respiratory
problems. B. Perform a comprehensive health history with the patient to review prior respiratory
problems. C. Perform a physical assessment of the respiratory system and ask specific questions related
to this episode of respiratory distress. D. Complete a full physical examination to determine the effect of
the respiratory distress on other body functions. - (answer)C. Perform a physical assessment of the
respiratory system and ask specific questions related to this episode of respiratory distress.Because the
patient is having respiratory difficulty, the nurse should ask specific questions about this episode and
perform a physical assessment of this system. Further history taking and physical examination of other
body systems can proceed once the patient's acute respiratory distress is being managed.
The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician
orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide
to the patient about the procedure? A. This test involves injection of a radioisotope to outline the blood
vessels in the lungs, followed by inhalation of a radioisotope gas. B. This test will use special technology
