respiration
A nurse is assessing a patient with COPD who is sitting in the tripod position with pursed-lip breathing. Which interpretation is most appropriate?
A. The patient is compensating to keep airways open and promote gas exchange
B. The patient’s breathing technique is causing increased CO₂ retention
C. The posture is unrelated to ventilation and instead improves cardiac output
D. The position is used to relax accessory muscles and decrease respiratory effort
A. The patient is compensating to keep airways open and promote gas exchange
A patient reports chest pain and palpitations after climbing stairs. The nurse reviews the patient’s lifestyle history. Which finding most increases risk for cardiovascular disease?
A. Consuming 1–2 alcoholic drinks per week
B. Sedentary job with little scheduled exercise
C. Occasional use of caffeine
D. Balanced diet with moderate sodium
B. Sedentary job with little scheduled exercise
The nurse schedules a pulmonary function test to measure the amount of air left in a client’s lungs at maximal expiration. What test does the nurse order?
A. Tidal volume (TV)
B. Total lung capacity
C. Residual volume
D. Forced expiratory volume
C. Residual volume
A nurse is caring for a postoperative patient at risk for DVT. Which nursing action is a priority for preventing venous stasis?
A. Increasing oral fluids to prevent dehydration
B. Encouraging hourly ambulation as tolerated
C. Applying warm compresses to both legs
D. Placing legs in a dependent position
B. Encouraging hourly ambulation as tolerated
A nurse is assessing an apical pulse. Which location is correct?
A. Right sternal border, 2nd intercostal space
B. Midclavicular line, 5th intercostal space
C. Midclavicular line, 3rd intercostal space
D. Left sternal border, 4th intercostal space
B. Midclavicular line, 5th intercostal space
During a focused respiratory and cardiovascular assessment, which finding is most concerning for impaired gas exchange?
A. Low-grade fever and productive cough
B. Spo₂ 90% on room air with normal respiratory effort
C. Mental confusion
D. Accessory muscle use during stair climbing only
C. Mental confusion
A nurse is assessing a patient with suspected left-sided heart failure. Which finding requires immediate follow-up?
A. Jugular venous distension
B. Crackles in the bilateral lower lung fields
C. Pitting edema in both ankles
D. Ascites
B. Crackles in the bilateral lower lung fields
Which assessment finding indicates impaired arterial circulation to the lower extremities?
A. Warm skin and brown discoloration
B. Dependent edema and weeping fluid
C. Hair loss and cool, pale skin on the legs
D. 3+ pedal pulses bilaterally
C. Hair loss and cool, pale skin on the legs
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
a. Ask the client what factors contribute to nonadherence.
b. Contact the health care provider to report the client’s current status.
c. Explain the use of a BiPAP mask instead of a CPAP mask.
d. Document outcomes of modifications in care.
A. Ask the client what factors contribute to nonadherence.
A patient with new-onset dyspnea is being assessed. Which finding indicates the patient is experiencing impaired oxygen exchange?
A. Respiratory rate of 20/min
B. Spo₂ at 88% on room air
C. Clear breath sounds
D. Normal capillary refill
B. Spo₂ at 88% on room air
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
A. They are loud, high-pitched sounds heard primarily over the trachea and larynx.
B. They are medium-pitched blowing sounds heard over the major bronchi.
C. They are low-pitched, soft sounds heard over peripheral lung fields.
D. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
C. They are low-pitched, soft sounds heard over peripheral lung fields.
A nurse caring for a patient with right-sided heart failure should monitor for which priority manifestation?
A. Pulmonary crackles
B. Jugular venous distension
C. Pink frothy sputum
D. Severe hypertension
B. Jugular venous distension
During a cardiac assessment, the nurse hears a blowing, swooshing sound over the mitral area. What is the most likely cause?
A. Increased chest wall thickness
B. Normal S1 and S2 heart tones
C. Turbulent blood flow through a valve
D. Decreased preload
C. Turbulent blood flow through a valve
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply.
A. Inhale slowly through the nose for a count of three.
B. Keep abdominal muscles in a relaxed state.
C. Shape the lips as if you were about to blow a whistle.
D. Over time, begin to increase the length of the exhale.
E. Exhale slowly through pursed lips.
F. Ensure that the exhale lasts twice as long as the inhale.
A. Inhale slowly through the nose for a count of three.
C. Shape the lips as if you were about to blow a whistle.
D. Over time, begin to increase the length of the exhale.
E. Exhale slowly through pursed lips.
F. Ensure that the exhale lasts twice as long as the inhale.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
A. Take in a small amount of air very quickly and then exhale as quickly as possible.
B. “Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly.”
C. Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly.”
D. Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling.”
C. Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly.”
A patient is experiencing increased work of breathing with use of the trapezius muscles during inspiration. Which interpretation by the nurse is most accurate?
A. The patient is demonstrating normal age-related changes in chest expansion
B. This finding indicates early respiratory distress requiring further evaluation
C. It is expected during deep breathing exercises and indicates improved ventilation
D. The finding reflects decreased airway resistance and improved airflow
B. This finding indicates early respiratory distress requiring further evaluation
A nurse is caring for a patient with new-onset atrial fibrillation. Which assessment finding requires priority follow-up?
A. Heart rate of 120 and irregular
B. Fatigue with exertion
C. Diminished peripheral pulses
D. Decreased level of consciousness
D. Decreased level of consciousness
A nurse is assessing a patient with worsening dyspnea and fatigue. Which assessment finding most strongly indicates left-sided heart failure?
A. Bounding peripheral pulses with warm, flushed skin
B. Elevated jugular venous pressure with abdominal distension
C. Bilateral crackles that do not clear with coughing
D. Brown discoloration and edema in both lower legs
C. Bilateral crackles that do not clear with coughing
A nurse is teaching a patient with newly diagnosed hypertension about health promotion. Which statement indicates the need for further teaching?
A. “I will reduce sodium intake to help lower my blood pressure.”
B. “I’ll stop smoking to reduce strain on my heart.”
C. “I only need to take my medication when I feel symptoms.”
D. “I will begin walking 30 minutes per day.”
C. “I only need to take my medication when I feel symptoms.”
A nurse arrives to find an unresponsive patient with no pulse. What action should be done first according to CPR sequence?
A. Provide two rescue breaths
B. Check carotid pulse for 30 seconds
C. Begin chest compressions
D. Apply the AED immediately
C. Begin chest compressions
A patient presents with wheezing during expiration. Which pathophysiological process most likely explains this finding?
A. Air moving through alveoli filled with fluid
B. Secretions or swelling causing narrowed airways
C. Airway collapse related to diminished surfactant
D. Inflammation of the pleura impairing lung expansion
B. Secretions or swelling causing narrowed airways
A patient is undergoing a peripheral vascular assessment. Which finding suggests impaired lymphatic function?
A. Bilateral dependent edema that resolves with elevation
B. Non-pitting, firm edema that does not improve with elevation
C. Red, warm area over the calf muscle
D. Hairless, cool skin on both feet
B. Non-pitting, firm edema that does not improve with elevation
A nurse caring for a patient with heart failure notes 3+ peripheral edema. Which action best demonstrates correct application of the nursing process?
A. Document the edema and notify the provider
B. Increase daily fluid intake to support perfusion
C. Assess lung sounds and vital signs before intervening
D. Elevate the patient’s legs and apply compression stockings
C. Assess lung sounds and vital signs before intervening
A patient with respiratory difficulty has difficulty coughing effectively. Which intervention is most appropriate to assist airway clearance?
A. Encourage nasal breathing to decrease airway irritation
B. Use splinting techniques during coughing episodes
C. Increase activity immediately to mobilize secretions
D. Place the patient in supine position to maximize force generation
B. Use splinting techniques during coughing episodes
A nurse is evaluating a patient with suspected DVT. Which finding best supports impaired venous return?
A. Cool, pale extremity with diminished pulses
B. Unilateral calf swelling with warmth and tenderness
C. Hair loss and thickened toenails
D. Dependent rubor that resolves with elevation
B. Unilateral calf swelling with warmth and tenderness