Nclexpn Quiz: Respiratory Status Monitoring And Support

20 questions · exam conditions

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Respiratory Status Monitoring And SupportQuestion 1 of 20

A nurse is caring for a 68-year-old client with a history of Chronic Obstructive Pulmonary Disease (COPD) in an acute care setting. The client is currently receiving 2 L/min of oxygen via nasal cannula. During the hourly round, the nurse observes the client is using pursed-lip breathing, appears restless, and is leaning forward on the over-bed table. The client's current oxygen saturation (SpO2) is 86%.

Which action should the nurse take first?

Increase the oxygen flow rate to 6 L/min via a simple face mask.

Assist the client into a high-Fowler's position and encourage deep breathing.

Notify the primary health care provider (PHCP) of the decrease in SpO2.

Perform a focused assessment of the client's lung sounds and chest expansion.

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Nclexpn Quiz

Nclexpn Quiz: Respiratory Status Monitoring And Support

Practice Respiratory Status Monitoring And Support in Nclexpn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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This quiz focuses on Respiratory Status Monitoring And Support, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexpn.

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Question 1

Which action should the nurse take first?

Increase the oxygen flow rate to 6 L/min via a simple face mask.
Assist the client into a high-Fowler's position and encourage deep breathing. (correct answer)
Notify the primary health care provider (PHCP) of the decrease in SpO2.
Perform a focused assessment of the client's lung sounds and chest expansion.

Explanation: Repositioning the client to a high-Fowler's or orthopneic position is an immediate, independent nursing action that improves lung expansion and reduces the work of breathing. It should precede other interventions because it can produce rapid relief without risk. Choice D (focused lung assessment) is a strong competing option, but the nurse has already performed observation-level assessment — tripod positioning, pursed-lip breathing, and SpO2 reading — which is sufficient to justify an immediate independent intervention before conducting a deeper assessment. Choice A (increasing O2 to 6 L/min) risks suppressing the hypoxic respiratory drive in a COPD client and should not be the first action. Choice C (notifying the PHCP) is appropriate but follows an independent intervention and further assessment.

Question 2

A nurse is caring for a client who had a permanent tracheostomy placed three days ago. While performing tracheostomy care, the nurse notes that the client has a large amount of thick, tenacious secretions. The nurse prepares to perform tracheostomy suctioning to clear the airway.

Which action should the nurse take to ensure safe suctioning for this client?

Limit each suction pass to no more than 10 to 15 seconds. (correct answer)
Apply continuous suction while inserting the catheter into the tracheostomy.
Use a suction pressure setting of 150 to 200 mmHg for an adult.
Encourage the client to hold their breath during the entire procedure.

Explanation: Limiting each suctioning pass to no more than 10 to 15 seconds is the standard safety parameter to prevent hypoxia and mucosal trauma. The nurse should also pre-oxygenate before each pass and allow recovery time between passes. Applying continuous suction during insertion (B) is incorrect; suction should be applied intermittently only while withdrawing the catheter, not during insertion, to prevent mucosal damage and hypoxia. A suction pressure of 150 to 200 mmHg (C) is excessive for adults; the recommended range is 80 to 120 mmHg to prevent airway trauma. Instructing the client to hold their breath (D) is incorrect and counterproductive; clients are encouraged to cough during the procedure to help mobilize secretions.

Question 3

A 45-year-old client is admitted to the medical unit with a diagnosis of bacterial pneumonia. The nurse's baseline assessment reveals crackles in the right lower lobe and a respiratory rate of 20 breaths/min. Two hours later, the nurse notes the client is now using accessory muscles to breathe, has a respiratory rate of 30 breaths/min, and is complaining of not being able to catch their breath.

Which action should the nurse perform first?

Administer the first dose of the prescribed IV antibiotic.
Check the client's SpO2 using a pulse oximeter. (correct answer)
Encourage the client to use an incentive spirometer.
Prepare the client for a stat portable chest X-ray.

Explanation: The client is showing signs of acute respiratory deterioration — accessory muscle use, tachypnea, and subjective air hunger. The nurse must first collect focused data by measuring SpO2 to quantify the severity of gas exchange impairment before intervening or notifying the PHCP. This step takes seconds and immediately informs urgency. Administering the antibiotic (A) treats the underlying infection but does not address the acute respiratory deterioration. Incentive spirometry (C) is inappropriate during active respiratory distress. Preparing for a chest X-ray (D) is a dependent action that follows assessment and provider notification, not precedes them.

Question 4

Client: 60-year-old female, history of heart failure and hypertension. Admission Status: Admitted for acute shortness of breath and peripheral edema. 0700 Baseline: Alert and oriented. BP 150/90 mmHg, HR 88 bpm, RR 18, SpO2 94% on room air. Lung sounds: Fine crackles at the bases bilaterally. 0900 Situation: The client reports increased difficulty breathing while lying flat. She appears anxious and is coughing up small amounts of pink, frothy sputum. 0905 Assessment: BP 162/96 mmHg, HR 112 bpm, RR 28, SpO2 88%. Lung sounds: Coarse crackles heard midway up the lung fields.

Which assessment finding is the most critical indicator of worsening pulmonary edema?

The increase in blood pressure to 162/96 mmHg.
The presence of pink, frothy sputum. (correct answer)
The increase in heart rate to 112 bpm.
The peripheral edema in the lower extremities.

Explanation: Pink, frothy sputum is pathognomonic for acute pulmonary edema — it signals that fluid under pressure is being forced from the pulmonary capillaries directly into the alveoli, severely impairing gas exchange. This is a high-priority, specific indicator of a life-threatening change in status. The blood pressure elevation (A) and tachycardia (C) are consistent with cardiovascular compensation but are non-specific findings that could have multiple causes. Peripheral edema (D) reflects systemic fluid retention, which is a chronic component of heart failure and is not an acute indicator of the current pulmonary crisis.

Question 5

The nurse recognizes that the client's report of increased difficulty breathing while lying flat (orthopnea) is most likely caused by:

A sudden pulmonary embolism.
Increased venous return and fluid shifting into the lungs. (correct answer)
An adverse reaction to her hypertension medication.
Ineffective use of her accessory muscles.

Explanation: In left-sided heart failure, the supine position increases venous return to the right heart. The failing left ventricle cannot adequately pump this increased volume forward, causing a backup of fluid into the pulmonary circulation and alveoli — producing orthopnea. This is a classic and expected pathophysiological mechanism in decompensated heart failure. A pulmonary embolism (A) would cause sudden-onset dyspnea but is not position-dependent in the way orthopnea is. An adverse medication reaction (C) is not supported by the clinical picture. Accessory muscle use (D) is a compensatory response to the dyspnea, not its cause.

Question 6

Which intervention should the nurse immediately implement to improve the client's respiratory status?

Place the client in a high-Fowler's position with the feet dangling. (correct answer)
Administer a prescribed oral beta-blocker.
Perform vigorous chest physiotherapy to clear the sputum.
Encourage the client to lie on her left side to improve cardiac output.

Explanation: High-Fowler's position with feet dangling is the priority independent nursing intervention for acute pulmonary edema. It simultaneously maximizes lung expansion by allowing full diaphragmatic excursion and reduces preload by promoting venous pooling in the dependent lower extremities — directly targeting the underlying pathophysiology. Administering an oral beta-blocker (B) is dangerous in the setting of acute decompensated heart failure; negative inotropic effects could worsen cardiac output. Vigorous chest physiotherapy (C) is inappropriate and potentially harmful during acute respiratory distress. Placing the client supine or lateral (D) would worsen venous return and further compromise the failing ventricle.

Question 7

The PHCP prescribes a STAT dose of IV furosemide. Which action is a priority for the nurse after administering the medication?

Measure the client's weight daily at the same time.
Monitor the client's hourly urine output and SpO2. (correct answer)
Reinforce teaching about a low-sodium diet.
Document the client's peripheral edema level.

Explanation: After administering a STAT dose of IV furosemide for acute pulmonary edema, the immediate priority is evaluating treatment effectiveness. Hourly urine output confirms the diuretic is working (fluid is being removed from the vascular space), while SpO2 monitoring confirms the primary clinical goal — improved gas exchange — is being met. Daily weight (A) is an important ongoing monitoring tool for heart failure but is not an immediate post-medication action. Diet teaching (C) is appropriate but is not a priority during an acute emergency. Documenting edema level (D) is relevant but reflects a chronic peripheral finding rather than the acute pulmonary emergency being treated.

Question 8

A nurse is monitoring a client on a mechanical ventilator in the intensive care unit. The high-pressure alarm on the ventilator begins to sound.

Which action should the nurse take first?

Check the ventilator tubing for any disconnections or leaks.
Assess the client's airway for secretions and need for suctioning. (correct answer)
Increase the oxygen concentration setting on the ventilator.
Silence the alarm and wait to see if it clears on its own.

Explanation: A high-pressure alarm indicates the ventilator is encountering increased resistance when delivering a breath to the client. The most common causes are secretion accumulation, the client biting the tube, bronchospasm, or the client breathing against the ventilator. Assessing the client's airway and suctioning as needed directly addresses the most frequent cause and prioritizes patient safety over equipment inspection. Choice A (checking for disconnections) describes the correct response to a low-pressure alarm, which indicates a loss of circuit integrity; it is not the priority action for a high-pressure alarm. Increasing oxygen (C) does not address the source of the resistance. Silencing the alarm without investigation (D) is a serious safety violation.

Question 9

The nurse is caring for a client who has had a tracheostomy in place for 6 weeks. The nurse enters the room and finds the client has accidentally dislodged the tracheostomy tube while coughing. The client is showing signs of respiratory distress.

Which action should the nurse take immediately?

Cover the stoma with an occlusive dressing and call for help.
Place the client in a supine position to open the airway.
Use a manual resuscitation bag to provide breaths over the stoma.
Attempt to reinsert the tracheostomy tube using a spare obturator. (correct answer)

Explanation: For a client with an established, mature tracheostomy stoma (a tract that has been in place for several weeks), the immediate priority when the tube is accidentally dislodged is to reinsert the tracheostomy tube using the obturator. The tract is well-formed and will remain patent long enough to allow reinsertion, which directly restores a secure airway. This is appropriate within LPN/VN scope for an established stoma per most facility protocols. Covering the stoma with an occlusive dressing (A) is appropriate only for a laryngectomy client where oral/nasal ventilation is no longer possible — it would obstruct this client's only functional airway. Supine positioning (B) does not address the dislodged tube and delays definitive airway management. BVM over the stoma (C) is a correct rescue action if reinsertion is unsuccessful, but reinsertion is the first-line response for an established stoma.

Question 10

A 75-year-old client with viral influenza is being monitored for potential complications. The nurse notes the client has become increasingly confused over the last hour. The client's baseline SpO2 was 96%, but it is now 90% on room air.

The nurse should recognize that the client's confusion is most likely a clinical sign of:

Early onset of age-related dementia.
Hypoxemia and decreased oxygen delivery to the brain. (correct answer)
An adverse reaction to an antiviral medication.
Dehydration from decreased fluid intake.

Explanation: In older adults, altered mental status — including new-onset confusion — is frequently the earliest and most prominent clinical sign of hypoxemia. The brain is highly sensitive to oxygen deprivation, and as SpO2 drops, cerebral oxygenation decreases, producing confusion before other classic respiratory symptoms become apparent. The concurrent drop in SpO2 from 96% to 90% directly supports this explanation. Age-related dementia (A) is a chronic, progressive condition and would not present as acute confusion over one hour. An adverse medication reaction (C) is possible but not supported without additional evidence; the SpO2 change provides a more compelling clinical explanation. Dehydration (D) could contribute to confusion but does not explain the concurrent SpO2 decline.

Question 11

The nurse is preparing to administer a prescribed nebulizer treatment of albuterol to a client with an acute asthma exacerbation.

Which finding should the nurse identify as an expected therapeutic outcome of this medication?

Increased heart rate and feelings of nervousness.
Decreased wheezing and increased ease of breathing. (correct answer)
Increased production of thick, white sputum.
Decreased blood pressure and increased drowsiness.

Explanation: Albuterol is a short-acting beta-2 agonist bronchodilator. Its therapeutic mechanism is relaxation of bronchial smooth muscle, which widens the airways and directly produces decreased wheezing and improved airflow. This is the intended clinical goal of administering the medication. Choice A (tachycardia and nervousness) describes common side effects of beta-agonist stimulation — they may occur but are not the desired therapeutic outcome. Choice C (increased thick sputum) is not an expected effect of albuterol; mucolytics address secretion consistency. Choice D (hypotension and drowsiness) is not associated with albuterol; these findings would suggest an adverse reaction requiring evaluation.

Question 12

A nurse is caring for a client who is two days post-thoracic surgery and has a chest tube. During the assessment, the nurse notes that the drainage in the collection chamber has increased from 20 mL/hour to 150 mL/hour of bright red blood over the last two hours.

What is the priority nursing action?

Document the findings and continue to monitor for another hour.
Clamp the chest tube to prevent further blood loss.
Notify the primary health care provider immediately. (correct answer)
Encourage the client to cough and deep breathe to clear the tube.

Explanation: Chest tube drainage exceeding 100 mL/hour, particularly when it is bright red blood and represents a sudden increase from a stable baseline rate, is a critical indicator of potential post-operative hemorrhage — a medical emergency requiring immediate PHCP notification. Documenting and waiting (A) is dangerous; hemorrhage can progress rapidly to hemodynamic instability. Clamping the chest tube (B) is contraindicated post-thoracic surgery because it can cause tension pneumothorax by trapping air or blood in the pleural space — this is one of the most important safety principles in chest tube management. Coughing and deep breathing (D) are appropriate preventive measures but do not address a hemorrhage emergency and could worsen bleeding.

Question 13

The nurse on a surgical unit is preparing to delegate the task of incentive spirometry reinforcement to a UAP for a stable client who had an appendectomy.

Which instruction by the nurse provides the UAP with the best direction?

Make sure the client uses the incentive spirometer 10 times every hour while awake. (correct answer)
Let me know if the client doesn't want to use the breathing machine today.
Check to see if the client is breathing better after they use the spirometer.
Tell the client to blow into the machine as hard as they can to get the ball up.

Explanation: Effective delegation provides a specific, measurable, and achievable task with clear parameters. Instructing the UAP to have the client use the spirometer 10 times every hour while awake gives a concrete, verifiable target that the UAP can complete and report on without requiring nursing judgment. Choice B does not provide any clinical parameters and essentially delegates the decision of whether to perform the intervention to the client. Choice C requires the UAP to assess respiratory status, which is a nursing function outside UAP scope. Choice D is incorrect for an additional critical reason beyond scope: incentive spirometry requires slow, maximal inhalation to raise the piston — not exhalation. Instructing the client to blow into the device is fundamentally wrong technique and would provide no therapeutic benefit.

Question 14

A client with a tracheostomy requires frequent suctioning. During the procedure, the nurse notes the client's heart rate increases from 80 to 120 bpm and the SpO2 drops from 95% to 88%.

Which action should the nurse take next?

Continue suctioning until the airway is completely clear.
Stop suctioning immediately and provide 100% oxygen. (correct answer)
Notify the PHCP that the client is not tolerating the procedure.
Document the changes in vital signs and finish the tracheostomy care.

Explanation: When a client develops signs of physiological distress during suctioning — specifically tachycardia and a significant SpO2 drop — the nurse must stop the procedure immediately and administer 100% oxygen via the tracheostomy to restore oxygenation. Suctioning removes oxygen along with secretions, and continuing despite distress (A) risks inducing dangerous hypoxia or cardiac arrhythmia. This is the standard safety protocol: stop, oxygenate, allow the client to stabilize, and only resume suctioning if clinically necessary after recovery. Notifying the PHCP (C) may be appropriate if distress persists after oxygenation, but it is not the first action. Documenting and continuing (D) ignores a clinically significant and potentially life-threatening response.

Question 15

Based on the pink, frothy sputum and coarse crackles, which nursing hypothesis is the priority?

Impaired gas exchange related to pulmonary congestion. (correct answer)
Risk for infection related to fluid stasis in the lungs.
Anxiety related to difficulty breathing.
Decreased cardiac output related to hypertension.

Explanation: Impaired gas exchange is the immediate life-threatening priority, evidenced by an SpO2 of 88%, RR of 28, and clinical signs of acute pulmonary edema. This is the hypothesis that, if left unaddressed, poses the greatest immediate risk to the client's survival. Risk for infection (B) is a secondary concern; fluid stasis may increase infection risk over time but is not immediately life-threatening. Anxiety (C) is real and warrants attention but is secondary to the physiological emergency. Decreased cardiac output (D) is the underlying pathophysiology driving the presentation, but impaired gas exchange is its most urgent and measurable consequence requiring immediate nursing action.

Question 16

The nurse is caring for a client with a left-sided chest tube that was placed for a pneumothorax. During the assessment of the closed-chest drainage system, the nurse observes that the water in the water-seal chamber is fluctuating (tidaling) with each breath the client takes.

How should the nurse interpret this finding?

The chest tube is obstructed and requires immediate milking.
There is a new air leak in the system that must be located.
The system is functioning normally as the lung expands. (correct answer)
The suction control chamber is not set to the correct pressure.

Explanation: Tidaling — the rhythmic fluctuation of the water level in the water-seal chamber with each breath — is a normal and expected finding in a chest tube drainage system. It indicates the system is patent and the pleural space is communicating appropriately with the drainage unit. Importantly, cessation of tidaling is the concerning finding, as it may indicate either successful lung re-expansion (desired) or tube obstruction (undesired), requiring further assessment to differentiate. Obstruction (A) would stop tidaling, not cause it. An air leak (B) is identified by continuous bubbling in the water-seal chamber, not by tidaling. Suction pressure issues (D) are assessed in the suction control chamber, which is a separate component.

Question 17

The nurse is reinforcing teaching with a client who was recently diagnosed with asthma and has been prescribed a fluticasone metered-dose inhaler (MDI) for long-term control. The nurse is discussing the importance of proper technique to ensure the medication reaches the lower airways.

Which instruction is most important to prevent a complication specific to this medication?

Inhale the medication quickly and forcefully as soon as you depress the canister.
Hold your breath for at least 10 seconds after inhaling the medication.
Wait at least 5 minutes between puffs if two puffs are prescribed.
Rinse your mouth with water and spit it out after using the inhaler. (correct answer)

Explanation: Fluticasone is an inhaled corticosteroid. Rinsing the mouth with water and spitting after each use is the most important instruction specific to this medication class because it prevents oral candidiasis (thrush) — a direct complication of corticosteroid deposition in the oropharynx. The stem asks for the instruction most important to prevent a medication-specific complication, making D the single best answer. Choice B (holding the breath for 10 seconds) is correct general MDI technique but is not specific to fluticasone or its complications. Choice A describes incorrect technique regardless of medication. Choice C overstates the required wait time between puffs of the same medication.

Question 18

The nurse is collecting data for a client with a history of chronic bronchitis who reports a smoker's cough that is worse in the morning. The nurse is reinforcing teaching on ways to assist with thinning and expectorating secretions.

Which instruction should the nurse reinforce?

Limit your fluid intake to 1 liter per day to prevent fluid in the lungs.
Perform deep breathing and coughing exercises every four hours.
Take an over-the-counter cough suppressant before you go to bed.
Use a humidifier in your bedroom during the night. (correct answer)

Explanation: A humidifier adds moisture to inspired air overnight, which directly addresses the goal of thinning secretions — making them less viscous and easier to mobilize. This is the most foundational teaching point for this specific goal because secretions must be adequately thinned before they can be effectively cleared. Choice B (deep breathing and coughing exercises) addresses expectoration — the mechanics of clearing secretions — but is less effective if the secretions remain thick; thinning comes first. Additionally, coughing every four hours is a reasonable preventive schedule but is not the primary intervention for thinning. Choice A (limiting fluids to 1 L/day) is directly contraindicated; adequate systemic hydration is essential for keeping pulmonary secretions thin. Choice C (cough suppressant at bedtime) is contraindicated for a productive cough; suppressing a productive cough causes secretion retention and increases the risk of infection.

Question 19

Two hours later, the client's RR is 20, SpO2 is 95% on room air, and she states she can breathe much better now. The nurse determines the interventions were successful because:

The client's blood pressure has returned to its baseline.
The client is no longer coughing up any sputum.
The respiratory status has stabilized toward the client's baseline. (correct answer)
The client is able to perform activities of daily living.

Explanation: The primary treatment goal was to restore adequate oxygenation and ventilation. A return of RR to 20 breaths/min and SpO2 to 95% on room air — alongside the client's subjective report of improvement — represents measurable stabilization toward the client's admission baseline and confirms effective treatment. Choice A is not a valid success indicator in this scenario: the client's 'baseline' blood pressure was 150/90 mmHg on admission, which itself reflects poorly controlled hypertension; returning to that value is not a therapeutic goal. Choice B (no sputum) is a supportive secondary finding but not the primary outcome measure. Choice D (ADL performance) is an unrealistic short-term goal two hours into treatment of an acute pulmonary emergency.

Question 20

A nurse is caring for an infant admitted with bronchiolitis. The nurse notes the infant has nasal flaring, intercostal retractions, and a grunting sound during expiration.

The nurse should recognize these findings as indicators of:

A normal physiological response to a viral infection.
Significant respiratory distress and increased work of breathing. (correct answer)
The infant reaching a higher level of activity and play.
A need for the infant to be fed immediately.

Explanation: Nasal flaring, intercostal retractions, and expiratory grunting constitute the classic triad of significant respiratory distress in infants and require immediate nursing assessment and intervention. Nasal flaring indicates the infant is attempting to maximize airway diameter. Intercostal retractions reflect the use of accessory muscles as the infant struggles to generate sufficient negative pressure to move air. Expiratory grunting is a physiological response — the infant partially closes the glottis on exhalation to maintain positive end-expiratory pressure and prevent alveolar collapse. Together, these are never normal and always indicate significant work of breathing. Choices A, C, and D offer benign interpretations that would delay necessary intervention.