Fund 7 Welcome to your Respiratory 1. None 2. A nurse is providing tracheostomy care for a client. During suctioning, the client suddenly develops tachycardia and oxygen saturation drops from 96% to 88%. Which action should the nurse take first? Stop suctioning and administer 100% oxygen. Increase suction pressure to remove secretions faster. Continue suctioning while reassuring the client. Remove the tracheostomy tube and replace it with a new one. None 3. A nurse is positioning a client for postural drainage due to copious lung secretions. Which of the following positioning techniques are appropriate? (Select all that apply.) Place the client in Trendelenburg position for lower lung lobe drainage. Position the client in a high Fowler’s position for apical lobe drainage. Encourage the client to lie prone to drain the posterior lower lobes. Position the client on their left side to drain the right middle lobe. Perform chest physiotherapy before postural drainage for better secretion mobilization. 4. A nurse is caring for a client with pneumonia. The client is receiving oxygen therapy via nasal cannula at 3 L/min. During the assessment, the nurse notes that the client's SpO₂ is 88%, and the client is experiencing increased work of breathing and restlessness. Question: Which of the following nursing actions should the nurse take first? Confirm the placement of the pulse oximeter probe Increase the oxygen flow rate to 4 L/min Place the client in semi-Fowler’s or Fowler’s position Encourage the client to take deep breaths None 5. A nurse is prioritizing care for multiple clients on a medical-surgical unit. Which of the following clients is at the highest risk for developing airway compromise and requires immediate intervention? Question: Which client should the nurse assess first? A 78-year-old client with pneumonia who has an SpO₂ of 94% and is receiving oxygen via nasal cannula at 2 L/min A 45-year-old client with chronic bronchitis who has a productive cough and is scheduled for a chest physiotherapy session A 60-year-old client with a tracheostomy who has thick secretions and is experiencing difficulty clearing them A 30-year-old client with asthma who has wheezing but reports symptom improvement after using an albuterol inhaler None 6. A nurse is monitoring a client receiving oxygen therapy at 60% FiO₂ for more than 48 hours. The client reports fatigue and substernal chest pain. The nurse suspects oxygen toxicity and must take action. Question: Which of the following interventions should the nurse implement? Increase the oxygen flow rate to prevent further hypoxia Immediately discontinue oxygen therapy to prevent lung damage Titrate the oxygen to the lowest level necessary to maintain SpO₂ within the prescribed range Administer bronchodilators to reduce oxygen toxicity effects None 7. A nurse is caring for a client receiving oxygen therapy via nasal cannula at 5 L/min. The nurse notices that the client’s nasal mucosa appears dry, and there is redness around the ears where the tubing rests. Question: Which of the following interventions should the nurse implement? (Select all that apply.) Use a water-soluble gel to prevent nasal dryness Increase the oxygen flow rate to 6 L/min Provide humidification for oxygen therapy Loosen the tubing around the ears and use padding Apply petroleum jelly to the nares for moisture Check Answer 8. A nurse is caring for a quadriplegic client who has been admitted for pneumonia. The nurse notes that the client has adventitious lung sounds and a weak cough effort. Question: Which of the following interventions should the nurse implement to promote airway clearance? (Select all that apply.) Encourage the client to cough and deep breathe frequently Suction the airway as needed to remove secretions Place the client in a high-Fowler’s position Restrict oral fluid intake to prevent excess mucus production Apply a non-rebreather mask to maximize oxygen delivery Check Answer 9. A nurse is caring for a client with chronic bronchitis who is receiving oxygen via nasal cannula at 2 L/min. The client’s SpO₂ drops to 87%, and they report shortness of breath and increased anxiety. Question: Which of the following actions should the nurse take first? Increase the oxygen flow rate to 4 L/min Place the client in a high-Fowler’s position Encourage the client to use pursed-lip breathing Obtain an arterial blood gas (ABG) sample None 10. A nurse is caring for a client who was admitted with acute respiratory distress syndrome (ARDS). The client is receiving oxygen via a non-rebreather mask at 12 L/min and suddenly becomes agitated and confused. Question: Which of the following actions should the nurse take first? Assess for proper function of the oxygen delivery system Administer a prescribed sedative to calm the client Obtain an arterial blood gas (ABG) sample Call the rapid response team (RRT) for immediate intervention None 11. A nurse is caring for four clients receiving oxygen therapy. The nurse must determine which client requires immediate intervention. Question: Which of the following clients should the nurse see first? A client with asthma who has an SpO₂ of 93% and mild wheezing A client with COPD receiving oxygen via nasal cannula at 2 L/min who reports slight shortness of breath A client with pneumonia who has an SpO₂ of 89% and reports increasing dyspnea A client with a tracheostomy who has thick secretions and is coughing weakly None 12. A nurse is caring for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/min. The client’s SpO₂ has dropped to 88%, and they report shortness of breath and fatigue. Question: Which of the following actions should the nurse take first? Increase the oxygen flow rate to 4 L/min Encourage the client to use an incentive spirometer Reposition the client into a high-Fowler’s position Obtain an order for arterial blood gas (ABG) analysis None 13. A nurse is caring for a client who has an acute respiratory infection and is at risk for hypoxemia. The client is lying in bed and is already receiving oxygen therapy via nasal cannula at 2 L/min. The nurse notes that the client is having difficulty breathing and becomes increasingly restless. Question: Which of the following interventions is the nurse’s priority? Increase the oxygen flow rate to 6 L/min Assist the client to Fowler’s position Promote removal of pulmonary secretions Obtain a specimen for arterial blood gases (ABGs) None 14. A nurse is caring for four clients on a medical-surgical unit. The nurse must determine which client requires immediate intervention to prevent airway obstruction. Question: Which client should the nurse see first? A client with COPD receiving oxygen at 2 L/min who has a productive cough A client with pneumonia who has crackles and diminished breath sounds bilaterally A client with a new tracheostomy who has excessive secretions and is struggling to clear them A client with asthma who has mild expiratory wheezing but is speaking in full sentences None 15. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen via nasal cannula at 2 L/min. The nurse notes the client is confused, restless, and has an SpO₂ of 85%. Question: Which of the following actions should the nurse take first? Increase the oxygen flow rate to 5 L/min Reassess the SpO₂ using a different pulse oximeter probe site Place the client in a high-Fowler’s position and encourage pursed-lip breathing Prepare to intubate the client immediately None 16. A nurse is caring for a postoperative client who is receiving oxygen therapy via nasal cannula at 3 L/min. The nurse notes that the client’s SpO₂ has dropped to 89%, and the client is experiencing shallow respirations. Question: Which of the following actions should the nurse take first? Encourage the client to use an incentive spirometer Assess for proper placement of the nasal cannula Increase the oxygen flow rate to 5 L/min Initiate non-rebreather mask therapy None 17. A nurse is caring for a client with pneumonia who has been receiving oxygen therapy via nasal cannula at 4 L/min for the past two hours. The nurse reassesses the client to determine if the intervention has been effective. Question: Which of the following findings indicate that the oxygen therapy has been effective? (Select all that apply.) SpO₂ increased from 88% to 95% Client reports reduced shortness of breath Respiratory rate increased from 16 to 24 breaths per minute Client is now using accessory muscles to breathe Client’s skin color has improved from pale to pink Show Correct Answer 18. A nurse is caring for a client with a tracheostomy who required suctioning 15 minutes ago due to thick secretions and decreased oxygen saturation. The nurse needs to evaluate whether the suctioning was effective. Question: Which of the following findings indicate that no further suctioning is needed at this time? (Select all that apply.) SpO₂ increased from 88% to 96% Client’s breath sounds are clear upon auscultation Client remains restless and agitated Client is coughing up additional thick secretions Respiratory rate decreased from 30 to 18 breaths per minute Show Correct Answer 19. A nurse is caring for a client with acute kidney injury (AKI). The client’s ABG results are as follows: ABG Results: pH: 7.28 PaCO₂: 38 mmHg HCO₃⁻: 17 mEq/L PaO₂: 95 mmHg Question:Which of the following interventions should the nurse anticipate? Increase oxygen therapy to correct hypoxia Prepare to administer sodium bicarbonate as prescribed Encourage the client to breathe into a paper bag to retain CO₂ Instruct the client to use an incentive spirometer to promote lung expansion None 20. A nurse is assessing a client who is experiencing a panic attack and has been hyperventilating for the past 10 minutes. The client is lightheaded and reports numbness and tingling in their fingers and lips. The nurse reviews the client’s ABG results: ABG Results: pH: 7.49 PaCO₂: 30 mmHg HCO₃⁻: 24 mEq/L PaO₂: 98 mmHg Question:Which of the following conclusions should the nurse make based on these findings? Uncompensated respiratory alkalosis Partially compensated metabolic alkalosis Fully compensated respiratory alkalosis Uncompensated metabolic acidosis None 21. A nurse is assessing a client with an acute respiratory infection who is at risk for hypoxemia. The client is restless and irritable, with an SpO₂ of 89%. The nurse recognizes that early signs of hypoxia require immediate intervention. Question: Which of the following clinical findings should the nurse identify as an early sign of hypoxia? (Select all that apply.) Tachypnea Cyanosis Restlessness Bradycardia Hypertension Check answer 22. A nurse is reviewing the ABG results of a postoperative client who has been vomiting persistently for the past 12 hour ABG Results: pH: 7.50 PaCO₂: 40 mmHg HCO₃⁻: 30 mEq/L PaO₂: 95 mmHg Question:Which of the following best describes this acid-base imbalance? Uncompensated metabolic alkalosis Fully compensated metabolic alkalosis Uncompensated respiratory alkalosis Partially compensated metabolic alkalosis None 23. A nurse is reviewing ABG results for a client with diabetic ketoacidosis (DKA) who has been receiving intravenous insulin therapy for the past 4 hours. ABG Results: pH: 7.28 PaCO₂: 37 mmHg HCO₃⁻: 18 mEq/L PaO₂: 92 mmHg Question:What is the nurse’s priority action based on these findings? Continue the insulin infusion and reassess ABGs in 2 hours Prepare the client for intubation due to worsening acidosis Administer sodium bicarbonate as prescribed Increase the client’s oxygen flow rate to correct hypoxemia None 24. A nurse is reviewing the ABG results of a client with chronic obstructive pulmonary disease (COPD) who was admitted for respiratory distress. ABG Results: pH: 7.30 PaCO₂: 55 mmHg HCO₃⁻: 26 mEq/L PaO₂: 80 mmHg SpO₂: 92% Question:How should the nurse interpret these ABG results? Uncompensated metabolic acidosis Partially compensated metabolic alkalosis Uncompensated respiratory acidosis ully compensated respiratory acidosis None 25. A nurse is assessing a patient’s respiratory rate. Which of the following techniques should the nurse use to ensure an accurate measurement? Ask the patient to breathe normally and count for 15 seconds Count the respiratory rate immediately after taking the radial pulse Inform the patient that their breathing will be monitored Measure the respiratory rate after the patient has been walking None 26. A nurse is assessing a patient’s oxygen saturation using a pulse oximeter. Which of the following factors could lead to an inaccurate reading? The patient is wearing nail polish on their fingers The pulse oximeter probe is placed on the earlobe The patient is calm and at rest The room lighting is dim None 27. A nurse is monitoring a patient with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation reading of 88%. What is the most appropriate action for the nurse to take? Increase the oxygen flow rate immediately Reassess the oxygen saturation using a different finger Document the reading and continue to monitor Notify the healthcare provider and assess the patient’s condition None 28. A nurse is teaching a patient about the use of a pulse oximeter at home. Which statement by the patient indicates a correct understanding? "I should place the probe on my toe for an accurate reading." "I can use the pulse oximeter while my hand is cold." "I need to keep my hand still while the pulse oximeter is taking the reading." "I should remove any jewelry from my hand before using the pulse oximeter." None 29. A nurse is assessing a patient’s oxygen saturation and finds a reading of 95%. What should the nurse do next? Continue to monitor the patient and document the reading Assess the patient’s respiratory rate and effort Increase the oxygen flow rate to improve the saturation Contact the healthcare provider immediately None 30. A nurse is teaching a student how to assess the respiratory rate of a patient. Which statement by the student indicates a need for further education? "I should count each rise and fall of the chest as one breath." "It is okay to assess the respiratory rate while the patient is talking." "I should observe the patient's breathing without them knowing I am counting." "I should count the respiratory rate for a full minute if it is irregular." None 31. The nurse notes that a patient's respiratory rate is 8 breaths per minute. Which of the following terms should the nurse use to document this finding? Tachypnea Apnea Eupnea Bradypnea None 32. A nurse is assessing a patient’s oxygen saturation using a pulse oximeter. Which of the following factors could lead to an inaccurate reading? The patient is wearing nail polish on their fingers The pulse oximeter probe is placed on the earlobe The patient is calm and at rest The room lighting is dim None 33. The nurse notes that a patient's respiratory rate is 8 breaths per minute. Which of the following terms should the nurse use to document this finding? Tachypnea Apnea Eupnea Bradypnea None 34. A nurse is assessing a patient’s respiratory rate. Which of the following techniques should the nurse use to ensure an accurate measurement? Ask the patient to breathe normally and count for 15 seconds Count the respiratory rate immediately after taking the radial pulse Inform the patient that their breathing will be monitored Measure the respiratory rate after the patient has been walking None 35. Which of the following factors can cause an increase in a patient's respiratory rate? Hypothermia Narcotic analgesics Pain Sleep None 36. A nurse is monitoring a patient with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation reading of 88%. What is the most appropriate action for the nurse to take? Increase the oxygen flow rate immediately Reassess the oxygen saturation using a different finger Document the reading and continue to monitor Notify the healthcare provider and assess the patient’s condition None 37. A nurse is assessing a patient’s oxygen saturation and finds a reading of 95%. What should the nurse do next? Continue to monitor the patient and document the reading Assess the patient’s respiratory rate and effort Increase the oxygen flow rate to improve the saturation Contact the healthcare provider immediately None 38. A nurse is teaching a student how to assess the respiratory rate of a patient. Which statement by the student indicates a need for further education? "I should count each rise and fall of the chest as one breath." "It is okay to assess the respiratory rate while the patient is talking." "I should observe the patient's breathing without them knowing I am counting." "I should count the respiratory rate for a full minute if it is irregular." None 39. A nurse is teaching a patient about the use of a pulse oximeter at home. Which statement by the patient indicates a correct understanding? "I should place the probe on my toe for an accurate reading." "I can use the pulse oximeter while my hand is cold." "I need to keep my hand still while the pulse oximeter is taking the reading." "I should remove any jewelry from my hand before using the pulse oximeter." None 40. Which of the following factors can cause an increase in a patient's respiratory rate? Hypothermia Narcotic analgesics Pain Sleep None Time's up P Proctored Practice Post navigation Previous Previous post: Fund 6Next Next post: Fund 8
