ATI RN
NCLEX RN Questions on Respiratory System Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
Correct Answer: B
Rationale: The correct answer is B: 5 to 20 minutes. Plugging the tracheostomy tube for this duration allows the client to gradually adapt to breathing without the assistance of the tube. Initially, the client may experience increased respiratory effort, which helps improve lung function. Plugging the tube for too short a time (A) may not provide enough challenge for the client, while plugging it for too long (C, D) may cause distress or potential complications due to lack of oxygen. Therefore, the optimal time frame of 5 to 20 minutes ensures a safe and effective weaning process for the client.
Question 5 of 5
The nurse assesses wheezes in a patient with asthma and realizes that these breath sounds result from:
Correct Answer: D
Rationale: The correct answer is D because wheezes in asthma are caused by the movement of air through narrowed airways due to bronchoconstriction and inflammation. This narrowing leads to turbulent airflow, resulting in the characteristic high-pitched musical sound of wheezes. Increased thickness of respiratory secretions (A) may cause crackles, not wheezes. Use of accessory muscles (B) indicates respiratory distress but does not directly cause wheezes. Tachypnea and tachycardia (C) are common in asthma but do not directly cause wheezes. Thus, D is the most directly related to the pathophysiology of wheezes in asthma.