MS 19 Respiratory System
Which condition would most likely increase airway resistance?
A. Pulmonary fibrosis
B. Asthma
C. Pleural effusion
D. Pulmonary embolism
B. Asthma
A client with allergic rhinitis asks how to prevent future episodes. Which instruction should the nurse include?
A. “Use your prescribed antihistamine only when symptoms are severe.”
B. “Avoid known environmental triggers when possible.”
C. “Limit fluid intake to reduce nasal drainage.”
D. “Take aspirin for nasal congestion.”
B. “Avoid known environmental triggers when possible.”
A client with pneumonia has crackles in both lung bases, RR 28/min, and SpO₂ 89% on room air. What is the priority nursing action?
A. Encourage increased oral fluids
B. Administer prescribed oxygen
C. Obtain a sputum culture
D. Perform chest physiotherapy
B. Administer prescribed oxygen
A client recently informed that curative treatment is no longer effective says, “I don’t want to hear any more bad news. I’m sure the doctors are wrong.” The nurse recognizes this response is characteristic of which stage of dying?
A. Acceptance
B. Anger
C. Denial
D. Depression
C. Denial
A client describes pain as “deep, dull, and aching” in the joints and muscles. The nurse identifies this as which type of pain?
A. Superficial somatic pain
B. Visceral pain
C. Deep somatic pain
D. Neuropathic pain
C. Deep somatic pain
A nurse explains to a student that the movement of oxygen from the alveoli into the blood is known as:
A. Ventilation
B. Inspiration
C. Perfusion
D. Diffusion
D. Diffusion
Which finding in a client recovering from sinus surgery requires immediate nursing action?
A. Mild nasal drainage
B. Swelling around the eyes
C. Repeated swallowing
D. Complaints of sinus pressure
C. Repeated swallowing
A client with pleurisy reports sharp chest pain that worsens with deep breathing. Which intervention is most therapeutic?
A. Encourage forceful coughing
B. Place the client in high-Fowler’s position
C. Teach the client to splint the chest when breathing
D. Restrict oral fluids
C. Teach the client to splint the chest when breathing
A dying client says, “I feel like my life is being cut short. It’s not fair.” What is the nurse’s best response?
A. “Many people feel that way when they are dying.”
B. “You should try to focus on the positive things in your life.”
C. “Tell me more about what feels unfair to you.”
D. “Have you talked with your family about these feelings?”
C. “Tell me more about what feels unfair to you.”
A client reports burning, shooting pain in the leg months after a spinal cord injury. Which type of pain is this?
A. Nociceptive pain
B. Referred pain
C. Visceral pain
D. Neuropathic pain
D. Neuropathic pain
An older adult client is at higher risk for respiratory infection. Which age-related change contributes most to this risk?
A. Increased elasticity of lung tissue
B. Enhanced cough reflex
C. Decreased number of alveolar capillaries
D. Thickened mucus secretions
C. Decreased number of alveolar capillaries
A child returns from the PACU after a tonsillectomy. Which assessment requires immediate intervention?
A. Refusing to drink
B. Complains of throat pain
C. Vomits small amounts of old dark blood
D. Frequent swallowing while sleeping
D. Frequent swallowing while sleeping
A client has a positive Mantoux test. Which statement by the nurse is most accurate?
A. “This test confirms you currently have active tuberculosis.”
B. “This test shows you have been exposed to tuberculosis bacteria.”
C. “This test means you will need a lung biopsy.”
D. “This test proves that your symptoms are caused by TB.”
B. “This test shows you have been exposed to tuberculosis bacteria.”
Which client statement best demonstrates an understanding of palliative care?
A. “Palliative care will help me cure my illness.”
B. “Palliative care focuses on relieving symptoms and improving comfort.”
C. “Palliative care means I must stop all medical treatments.”
D. “Palliative care is only provided in the last 24 hours of life.”
B. “Palliative care focuses on relieving symptoms and improving comfort.”
Which finding is most consistent with acute pain?
A. Normal vital signs
B. Hopelessness and weight loss
C. Elevated blood pressure and heart rate
D. Dull pain lasting longer than 6 months
C. Elevated blood pressure and heart rate
During a respiratory assessment, which finding requires the most immediate follow-up?
A. Soft vesicular breath sounds in peripheral fields
B. Bilateral sonorous wheezes that clear with coughing
C. Asymmetrical chest expansion
D. Mild shortness of breath on exertion
C. Asymmetrical chest expansion
Which nursing intervention is most important for a client with a peritonsillar abscess?
A. Encourage warm fluids
B. Keep the head of bed flat
C. Monitor for signs of airway obstruction
D. Apply warm compresses to the neck
C. Monitor for signs of airway obstruction
Which finding indicates atelectasis in a post-operative patient?
A. Sudden onset of frothy sputum
B. Diminished breath sounds in lower lobes
C. High-pitched inspiratory wheezing
D. Barrel-shaped chest
B. Diminished breath sounds in lower lobes
Which intervention is most appropriate to relieve dry mucous membranes in a dying client?
A. Provide frequent oral care with moist swabs
B. Apply warm compresses to the lips
C. Restrict oral fluids to prevent aspiration
D. Offer salty snacks to stimulate saliva
A. Provide frequent oral care with moist swabs
Which action is essential when assessing a client’s pain?
A. Using a standardized pain assessment tool
B. Relying on nonverbal cues rather than client report
C. Comparing pain level to previous clients
D. Asking the family to verify the client’s pain level
A. Using a standardized pain assessment tool
A client with COPD has an ABG showing: pH 7.32, PaCO₂ 58 mmHg, HCO₃⁻ 27 mEq/L.
Which problem is the nurse most likely observing?
A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic acidosis
D. Metabolic alkalosis
B. Respiratory acidosis
A client with laryngitis reports persistent hoarseness for 3 weeks. Which action is most appropriate?
A. Encourage increased fluid intake
B. Suggest a warm saltwater rinse
C. Notify the provider for further evaluation
D. Teach the client to whisper instead of speaking
C. Notify the provider for further evaluation
A client with emphysema has an SpO₂ of 89%. The nurse administers low-flow oxygen at 2 L/min via nasal cannula. Why is low-flow oxygen used in this condition?
A. High oxygen improves airway resistance
B. High oxygen increases carbon dioxide elimination
C. High oxygen can decrease the client’s respiratory drive
D. High oxygen prevents atelectasis
C. High oxygen can decrease the client’s respiratory drive
Family members tell the nurse, “We don’t want to tell our mother she is dying because she will lose hope.” What is the nurse’s best response?
A. “I will respect your wishes and avoid discussing her prognosis.”
B. “Clients have a right to know about their condition if they ask.”
C. “You should tell her immediately so she can prepare.”
D. “The provider is responsible for sharing that information.”
B. “Clients have a right to know about their condition if they ask.”
Which nursing instruction is most important for a client using PCA morphine?
A. “Only the nurse should push the PCA button.”
B. “Push the button when the pain begins, not when it becomes severe.”
C. “Use the PCA only at scheduled times.”
D. “Wait until you are receiving maximum pain before pressing the button.”
B. “Push the button when the pain begins, not when it becomes severe.”