ATI RN
NCLEX RN Questions on Respiratory System Questions
Question 1 of 5
The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that the level of drainage has not increased over the last 3 hours. After assessing the patient’s respiratory status, what should the nurse do next?
Correct Answer: B
Rationale: The correct answer is B: Check the tubing for kinks. This is the best next step because stagnant drainage could be caused by a kink in the tubing, obstructing proper drainage. By checking for kinks, the nurse ensures proper functioning of the drainage system, preventing potential complications such as fluid buildup or infection. Raising the system above the patient's heart (A) may not address the underlying issue of kinked tubing. Repositioning the patient (C) may not be necessary if the drainage is not related to patient positioning. Notifying the physician (D) should be done after checking the tubing for kinks, as it is important to troubleshoot and address the issue promptly.
Question 2 of 5
Which assessment findings aren't consistent with a client diagnosis of right-sided heart failure?
Correct Answer: A
Rationale: The correct answer is A because collapsed neck veins are not consistent with right-sided heart failure. In right-sided heart failure, venous congestion leads to jugular venous distention, not collapse. Distended abdomen (choice B) occurs due to fluid accumulation in the abdomen, a common finding in right-sided heart failure. Dependent edema (choice C) results from fluid retention in the lower extremities, also seen in right-sided heart failure. Decreased appetite (choice D) can be present due to abdominal discomfort from fluid accumulation. Therefore, the presence of collapsed neck veins is the only assessment finding that is not indicative of right-sided heart failure.
Question 3 of 5
O2 dissociation curve shift to R) by all of the following except
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide. Carbon monoxide does not shift the O2 dissociation curve to the right (R) because it binds to hemoglobin with a higher affinity than oxygen, causing a leftward shift (L). Increased [H+], pCO2, and temperature all shift the curve to the right by decreasing hemoglobin's affinity for oxygen.
Question 4 of 5
The organs of the respiratory zone of the respiratory system include all the following EXCEPT:
Correct Answer: A
Rationale: The correct answer is A: trachea. The trachea is not part of the respiratory zone, which is where gas exchange occurs. The respiratory zone includes the small bronchioles, alveoli ducts, and alveoli. The trachea is part of the conducting zone, which is responsible for transporting air to and from the respiratory zone. Therefore, the trachea is not directly involved in gas exchange, making it the correct answer. The other choices, B: small bronchioles, C: alveoli ducts, and D: alveoli, are all part of the respiratory zone and play a crucial role in gas exchange.
Question 5 of 5
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?
Correct Answer: B
Rationale: The correct answer is B: Continue to monitor the client. Fluctuation of fluid level in the water seal chamber post chest tube insertion indicates proper functioning of the chest tube system. This signifies that the tube is effectively draining fluid or air from the pleural space. It is essential to continue monitoring the client to ensure ongoing proper functioning of the chest tube. Informing the physician (Choice A) is not necessary at this point unless there are other concerning symptoms. Reinforcing the occlusive dressing (Choice C) is not indicated unless there is a leak or issue with the dressing. Encouraging the client to deep breathe (Choice D) is unrelated to the assessment of the chest tube system.