NCLEX RN Questions on Respiratory System

NCLEX RN Questions on Respiratory System Related

Review NCLEX RN Questions on Respiratory System related questions and content

While assessing an acutely ill patient's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?

  • A. Eupnea
  • B. Apnea
  • C. Biot's respiration
  • D. Cheyne-Stokes
Correct Answer: C

Rationale: The correct answer is C: Biot's respiration. Biot's respiration is characterized by regular breathing interrupted by periods of apnea. In this scenario, the nurse observed normal breaths followed by a 20-second episode of apnea, which aligns with Biot's respiration. It is crucial to document this finding accurately to ensure appropriate care.

Incorrect answers:
A: Eupnea refers to normal breathing without any interruptions or irregularities. The presence of apnea in the scenario rules out eupnea.
B: Apnea would be an incomplete assessment as it does not capture the alternating pattern of normal breaths and apnea observed in Biot's respiration.
D: Cheyne-Stokes breathing involves a cyclical pattern of gradually increasing and decreasing breathing rates, which is not evident in the scenario described.

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When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?

  • A. Confusion
  • B. An abrupt onset of fever and chills
  • C. A recent loss of consciousness
  • D. A gradual onset of headache and sore throat
Correct Answer: B

Rationale: In patients with Community-Acquired Pneumonia (CAP), an abrupt onset of fever and chills is a common symptom to expect. This is due to the rapid inflammatory response in the lungs. Confusion, loss of consciousness, and gradual headache and sore throat are less likely to be reported initially.

Which assessment findings aren't consistent with a client diagnosis of right-sided heart failure?

  • A. Collapsed neck veins
  • B. Distended abdomen
  • C. Dependent edema
  • D. Decreased appetite
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.

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:

  • A. 15 to 60 seconds.
  • B. 5 to 20 minutes.
  • C. 30 to 40 minutes.
  • D. 45 to 60 minutes.
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.

The surface area of the alveoli is about

  • A. 80 m2
  • B. 70m2
  • C. 60m2
  • D. 90m2
Correct Answer: A

Rationale: The correct answer is A: 80 m2. The alveoli are tiny air sacs in the lungs where gas exchange occurs. The surface area of the alveoli is crucial for efficient gas exchange. The average adult human has around 300 million alveoli with a total surface area of about 70-100 m2, making option A the most accurate. Option B, C, and D are incorrect as they do not fall within the typical range of alveolar surface area. It is important to remember the importance of the large surface area of the alveoli in facilitating the exchange of oxygen and carbon dioxide during respiration.

In human beings, rib case and sternum move upwardly and outwardly during

  • A. Exercise
  • B. Sudden back injury
  • C. Expiration
  • D. Inspiration
Correct Answer: D

Rationale: During inspiration, the diaphragm contracts and moves downward, while the intercostal muscles contract to lift the rib cage and sternum upward and outward to increase lung volume for air intake. This creates a negative pressure in the lungs, allowing air to be drawn in. In contrast, expiration involves relaxation of the diaphragm and intercostal muscles, leading to the rib cage and sternum moving downward and inward to expel air. Therefore, the correct answer is D: Inspiration. Choices A, B, and C are incorrect as they do not specifically involve the physiological process of rib cage and sternum movement related to breathing.

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