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Exam (elaborations)

Respiratory System NCLEX 2022 Questions and Answers

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The most important action the nurse should do before and after suctioning a client is: a. Placing the client in a supine position b. Making sure that suctioning takes only 10-15 seconds c. Evaluating for clear breath sounds d. Hyperventilating the client with 100% oxygen Correct answer- d. Hy...

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  • April 8, 2022
  • 14
  • 2021/2022
  • Exam (elaborations)
  • Questions & answers
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Respiratory System NCLEX 2022
Questions and Answers

1. The most important action the nurse should do before and after suctioning a
client is:

a. Placing the client in a supine position
b. Making sure that suctioning takes only 10-15 seconds
c. Evaluating for clear breath sounds
d. Hyperventilating the client with 100% oxygen
Correct answer- d. Hyperventilating the client with 100% oxygen

2. The position of a conscious client during suctioning is:

a. Fowler's
b. Supine position
c. Side-lying
d. Prone
Correct answer- a. Fowler's

Position a conscious person who has a functional gag reflex in the semi fowler's
position with the head turned to one side for oral suctioning or with the neck
hyper extended for nasal suctioning. If the client is unconscious place the patient
a lateral position facing you.

3. Presence of overdistended and non-functional alveoli is a condition called:

a. Bronchitis
b. Emphysema
c. Empyema
d. Atelectasis
Correct answer- Answer: B.

An overdistended and non-functional alveoli is a condition called emphysema.
Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of
pus in the lung.

4. 23. The accumulation of fluids in the pleural space is called:

a. Pleural effusion
b. Hemothorax
c. Hydrothorax

, d. Pyothorax
Correct answer- a. Pleural effusion

5. 2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest
tube inserted notes continuous gentle bubbling in the suction control chamber.
What action is appropriate?

a. Do nothing, because this is an expected finding.
b. Immediately clamp the chest tube and notify the physician.
c. Check for an air leak because the bubbling should be intermittent.
d. Increase the suction pressure so that bubbling becomes vigorous.
Correct answer- Answer A.

Continuous gentle bubbling should be noted in the suction control chamber.

Option B is incorrect. Chest tubes should only be clamped to check for an air leak
or when changing drainage devices (according to agency policy).

Option C is incorrect. Bubbling should be continuous and not intermittent.

Option D is incorrect because bubbling should be gentle. Increasing the suction
pressure only increases the rate of evaporation of water in the drainage system.

6. The nurse caring for a male client with a chest tube turns the client to the side,
and the chest tube accidentally disconnects. The initial nursing action is to:

a. Call the physician.
b. Place the tube in a bottle of sterile water.
c. Immediately replace the chest tube system.
d. Place the sterile dressing over the disconnection site.
Correct answer- Answer B.

If the chest drainage system is disconnected, the end of the tube is placed in a
bottle of sterile water held below the level of the chest. The system is replaced if it
breaks or cracks or if the collection chamber is full. Placing a sterile dressing over
the disconnection site will not prevent complications resulting from the
disconnection. The physician may need to be notified, but this is not the initial
action.

7. While changing the tapes on a tracheostomy tube, the male client coughs and the
tube is dislodged. The initial nursing action is to:

a. Call the physician to reinsert the tube.
b. Grasp the retention sutures to spread the opening.
c. Call the respiratory therapy department to reinsert the tracheotomy.
d. Cover the tracheostomy site with a sterile dressing to prevent infection.
Correct answer- b. Grasp the retention sutures to spread the opening.

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