ATI RN
Respiratory System NCLEX Practice Questions Questions
Question 1 of 5
The nurse is caring for a client who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
Correct Answer: A
Rationale: The correct answer is A because a low O2 saturation level (88%) indicates potential respiratory compromise or hypoxemia post-thoracentesis, which requires immediate intervention to prevent hypoxia. The other choices are not as critical: B (BP slightly elevated but not urgent), C (RR slightly elevated but expected after procedure), and D (Pain at level 5 with deep breath is common post-thoracentesis and can be managed).
Question 2 of 5
The lungs are covered by a two-layer membrane called the:
Correct Answer: A
Rationale: The correct answer is A: pleura. The pleura is a two-layered membrane that covers the lungs. The outer layer is called the parietal pleura, which lines the chest wall, and the inner layer is called the visceral pleura, which covers the lungs themselves. This double-layered structure helps to protect and cushion the lungs during breathing movements. Summary of incorrect choices: B: The diaphragm is a dome-shaped muscle located below the lungs that plays a role in breathing but does not cover the lungs. C: The respiratory membrane refers to the interface where gas exchange occurs in the alveoli, not the covering of the lungs. D: The intercostal muscles are located between the ribs and assist in breathing but do not cover the lungs.
Question 3 of 5
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:
Correct Answer: B
Rationale: The correct initial nursing action is to choose option B: Grasp the retention sutures to spread the opening. This is because spreading the opening using the retention sutures can help maintain the airway patency until the tube is reinserted. Calling the physician (option A) or respiratory therapy department (option C) may cause delays in addressing the immediate airway obstruction. Covering the tracheostomy site with a sterile dressing (option D) does not address the primary concern of maintaining the airway. Therefore, option B is the most appropriate and effective action to take in this situation.
Question 4 of 5
For a male client with an endotracheal (ET) tube, which nursing action is most essential?
Correct Answer: A
Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed. Summary: - Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds. - Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement. - Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.
Question 5 of 5
In assessing for major sources of infection in a COPD patient, the nurse focuses on:
Correct Answer: A
Rationale: The correct answer is A: Stasis of respiratory secretions. In COPD patients, stasis of respiratory secretions can lead to bacterial growth and increase the risk of infections like pneumonia. This is a common issue in COPD due to impaired mucociliary clearance. Choices B, C, and D are not directly related to sources of infection in COPD patients. Low body weight is more associated with malnutrition, postural hypotension with cardiovascular issues, and delayed antigen-antibody response with immune system deficiencies.