Acute Respiratory Failure Questions (ati/FA/NClex)

Question 1

A nurse is caring for a client with pneumonia who is experiencing thick, oral secretions which of the following should the nurse take?
A. Provide chest physiotherapy.
B. Perform oropharyngeal suction
C. Encourage deep breathing and coughing
D. Assist the client with ambulation

Answer 1

C. Encourage deep breathing and coughing

Question 2

A client comes to the emergency department in severe respiratory distress. Following left, sided blunt chest trauma. The nurse notes absent breath sounds on the clients left side and a tracheal shift to the right for which of the following procedure. Should the nurse prepare the client?

A. Tracheostomy placement
B. Thoracentesis
C. CT scan of the chest
D. Chest tube insertion

Answer 2

D. Chest tube insertion

Question 3

A nurse is preparing a discharge teaching plan for six year client with asthma, who has several prescription medication’s using metered dose inhalers. Which of the following intervention should the nurse include in the plan?

A. Add a spacer to each MDI
B. Instruct the childhood more rapidly than usual, when using an MDI
C. The provider to change the medication from inhaled to oral formulation
D. Administer oxygen by facemask along with MDI

Answer 3

A. Add a spacer to each MDI

Question 4

A nurse is providing teaching to the parents at the school, a child with asthma about medication for bronchospasms, which of the following inhale medication. Should the nurse instruct the parents to use to relieve an acute asthma attack?

A. Salmeterol
B. Cromolyn
C. Fluticasone
D. Albuterol

Answer 4

D. Albuterol

Question 5

A nurse is preparing a client for discharge following a bronchoscopy, which of the following is a nurses monitoring priority?

A. Palpating, peripheral pulses
B. Osculating heart sounds
C. Confirming the gag reflex

Answer 5

C. Confirming the gag reflex

Question 6

A nurse is providing instructions about purse lip breathing for a client who has chronic obstructive, pulmonary disease (COPD) with emphysema this breathing technique accomplishes which of the following?

A. Increases oxygen intake
B. Promotes carbon dioxide elimination
C. Uses the intercostal muscles
D. Strengthen the diaphragm

Answer 6

B. Promotes carbon dioxide elimination

Question 7

A nurse is providing discharge, teaching about improving gas exchange for a client who has emphysema which of the following instructions should the nurse include in the teaching?

A. Use pursed-lip breathing during periods of dyspnea
B. Limit fluid intake to 1500 ML per day
C. Practice chest breathing each day
D. Wear home oxygen to maintain an SAO2 of at least 94%

Answer 7

A. Use pursed-lip breathing during periods of dyspnea

Question 8

A nurse is reviewing the laboratory results of a client who has metabolic alkalosis, which of the following laboratory values. Should the nurse expect?

A. PH 7.31, HCO3-22 mEq/L, PAC02 50 mmHg
B. PH 7.48, HC03- 23 mEq/L, PAC02 25 MMhg
C. PH 7.32, HC03 -18 mEq/L, PAC02 40 mmHg
D. PH 7.49, HC03 - 32 mEq/L, PAC02 40 mmHg

Answer 8

D. PH 7.49, HC03 - 32 mEq/L, PAC02 40 mmHg

Question 9

A nurse is caring for a client who extremely anxious and is hyperventilating. The clients ABG results are PH 7.50, PACO2 -27 mmHg and HCO3 25 mEq/L. The nurse should identify that the client has which of the following acid base and balances.?

A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis

Answer 9

C. Respiratory alkalosis

Question 10

Nurse is planning care for a client who is postoperative following a hip or arthroplasty in the clients medical record the nurse notes, a history of chronic obstructive pulmonary disease which of the following oxygen delivery method to the nurse plan to use for this client?

A. Simple facemask
B. Non-rebreather mask
C. Bag-valve-Mask device
D. Nasal cannula

Answer 10

D. Nasal cannula

Question 11

A nurse on the medical unit is caring for a client who is aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea, which of the following finding is a clinical manifestation of acute respiratory syndrome?

A. Tympanic temperature 100.4F
B. PAC02 50 mmHg
C. Rhonchi
D. Hypopnea

Answer 11

B. PAC02 50 mmHg

Question 12

A nurse is caring for a client who has been in the PACU for more than one hour has a respiratory rate of 9/min and its difficult to arouse. The nurse should expect a prescription for which of the following medications?

A. Pentazocine
B. Naloxone
C. naltrexone
D. Butorphanol

Answer 12

B. Naloxone

Question 13

A nurse is caring for a client who has a 20 year history of COPD, and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85% which of the following action should the nurse take?

A. Place a nonrebreather mask on the client and increased the oxygen flow to 3 L/min
B. Prepare the client for possible endotracheal intubation and mechanical ventilation
C. Increase the oxygen flow and request an arterial blood gas determination
D. Position the client supine and administer an anti-anxiety medication

Answer 13

C. Increase the oxygen flow and request an arterial blood gas determination

Question 14

A nurse is caring for a client home the respiratory therapist has just removed the endotracheal tube which of the following action should the nurse take first?

A. Instruct the client to cough
B. Administer oxygen via face-mask
C. Evaluate the client for stridor
D. Keep the client in a semi to high Fowlers position

Answer 14

C. Evaluate the client for stridor

Question 15

A nurse is caring for a client who has a tracheostomy with an inflated cup in place which of the following finding indicates the nurse, should suction the clients airway secretions?

A. The client is unable to speak
B. The clients airway secretions were last suctioned 2 hours ago
C. The client coughs and expectorates a large mucous plug
D. The nurse auscultates course crackles in the lung fields

Answer 15

D. The nurse auscultates course crackles in the lung fields

Question 16

The nurse is caring for a client who has chronic obstructive pulmonary disease and is experiencing shortness of breath which of the following action should the nurse perform first?

A. Monitor the clients ABG results
B. Instruct the to perform controlled coughing
C. Teach the client how to use pursed-lip breathing
D. Place the client in an upright position

Answer 16

D. Place the client in an upright position

Question 17

A nurse in a clinic is providing teaching for a client who is scheduled to have a tb skin test. Which of the following pieces of information should the nurse include?

A.” If the test is positive , it means you have an active case of tuberculosis”
B. “ if the test is positive, you should have another tuberculin skin test in 3 weeks”
C. “ you must return to the clinic to have the test read in 2 or 3 days “
D. “ a nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substances”

Answer 17

D. “ a nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substances”

Question 18

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

A. Total lung capacity
B. Vital lung capacity
C. Functional residual capacity
D. Residual volume

Answer 18

A. Total lung capacity

Question 19

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high -pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications ?

A. Pulmonary edema
B. Tension pneumothorax
C. Flail chest
D. Respiratory obstruction

Answer 19

D. Respiratory obstruction

Question 20

A nurse is auscultating a clients lungs and identifies Rhonchi over the trachea and bronchi. Which of the following actions should the nurse take?

A. Limit clients fluid intake
B. Assist the client into a supine position
C. Administer oxygen at 2L/min
D. Encourage the client to cough

Answer 20

D. Encourage the client to cough

Question 21

A nurse on a medical surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?

A. Increased coughing
B. Diaphragmatic breathing
C. Hemoptysis
D. Kussmaul respirations

Answer 21

A. Increased coughing

Question 22

A nurse on the medical surgical unit is caring for a client who is post op following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism?

A. Sudden onset of dyspnea
B. Tracheal deviation
C. Bradycardia
D. Difficulty swallowing

Answer 22

A. Sudden onset of dyspnea

Question 23

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor for which of the following acid base imbalances?

A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis

Answer 23

C. Respiratory acidosis

Question 24

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear?

A. Soft blowing
B. Loud bubbling
C. Dry grating
D. Noisy wheezing

Answer 24

D. Noisy wheezing

Question 25

A nurse is caring for a client who is receiving ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first ?

A. Initiate bag valve-mask ventilation
B. Provide the client with a communication board
C. Obtain a blood sample for ABG analysis
D. Document the ventilator settings

Answer 25

A. Initiate bag valve-mask ventilation

Question 26

A nurse is preparing to assist a provider with an arterial blood withdrawal from a clients radial artery for ABG measurements. Which of the following actions should the nurse plan to take?

A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen
B. Apply ice to the site after obtaining the specimen
C. Perform an Allen’s test prior to obtaining the specimen
D. Release the pressure applies to the puncture site 1 min after the needle is withdrawn

Answer 26

C. Perform an Allen’s test prior to obtaining the specimen

Question 27

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

A. Eat high-calorie foods first
B. Increase intake of water at meals
C. Perform active ROM exercises before meals
D. Keep saltine crackers nearby for snacking

Answer 27

A. Eat high-calorie foods first

Question 28

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team?

A. Stridor
B. Coughing
C. Hoarseness
D. Extensive oral secretions

Answer 28

A. Stridor

Question 29

A nurse in the ED is assessing a client who was in a MVC. Findings include absent breath sounds in the left lower lobe with dyspnea , blood pressure 118/68, HR 124, RR 38, temp 101.4 and SA02 of 92% on RA. Which of the following actions should the nurse take first ?

A. Obtain chest X-ray
B. Prepare for chest tube insertion
C. Administer oxygen via high flow mask
D. Initiate IV access

Answer 29

D. Initiate IV access

Question 30

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the newly licensed nurse indicates understanding for the teaching?

A. This medication is given to treat infection
B. This medication is given to facilitate ventilation
C. This medication is given to decrease inflammation
D. This medication is given to reduce anxiety

Answer 30

B. This medication is given to facilitate ventilation

Question 31

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome?
SATA

A. A client who experienced a near - drowning incident
B. A client following a coronary artery bypass graft surgery
C. A client who has a HGB of 15.1
D. A client who has dysphagia
E. A client who experienced acute drug toxicity

Answer 31

A. A client who experienced a near - drowning incident
B. A client following a coronary artery bypass graft surgery
D. A client who has dysphagia
E. A client who experienced acute drug toxicity

Question 32

A nurse is planning care for a client who has severe acute respiratory distress system. Which of the following actions should the nurse include ?
SATA

A. Administer antibiotics
B. Provide supplemental oxygen
C. Administer antiviral medication
D. Administer bronchodilator’s
E. Maintain ventilatory support

Answer 32

B. Provide supplemental oxygen
D. Administer bronchodilator’s
E. Maintain ventilatory support

Question 33

A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate administering with this medication?
SATA

A. Fentanyl
B. Furesomide
C. Midazolam
D. Famotidine
E. Dexamethasone

Answer 33

A. Fentanyl
C. Midazolam

Question 34

A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support (PSV)mode . Which of the following statements by the nurse indicate an understanding of PSV?

A.it keeps the alveoli open and prevents atelectasis
B. It allows preset pressure delivered during spontaneous ventilation
C. It guarantees minimal minute ventilator
D. It delivers a preset ventilatory rate and tidal volume to the client

Answer 34

B. It allows preset pressure delivered during spontaneous ventilation

Question 35

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize ?
SATA

A. Confusion
B. Pale skin’
C. Bradycardia
D. Hypotension
E. Elevated BP

Answer 35

B. Pale skin’

E. Elevated BP

Question 36

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse nurse take?

A. Apply a vest restraint if self-extubation is attempted
B. Monitor ventilator settings q 8hr
C. Document tube placement in centimeters at the angle of the jaw
D. Assess breath sounds every 4hr

Answer 36

D. Assess breath sounds every 4hr

Question 37

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver precise amount of oxygen to the client ?

A. Nonrebreather mask
B. Venturi mask
C. Nasal cannula
D. Simple face mask

Answer 37

B. Venturi mask

Question 38

A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the clients work of breathing ? SATA

A. Assist control
B. Synchronized intermittent mandatory ventilation
C. Continuous positive airway pressure
D.pressure support ventilation
E. Independent lung ventilation

Answer 38

B. Synchronized intermittent mandatory ventilation

C. Continuous positive airway pressure

D.pressure support ventilation

Question 39

A patient with a diagnosis of pneumonia complains of a new onset of slight SHOB, for which of the following assessment findings would the nurse call the primary care provider immediately?
SATA

A. The patient is voiding but the amounts are decreasing
B. The patient is sleeping more than usual
C. There is a pink coloration to the skin
D. The patients secretions are thin and milky colored
E. The patient thought it was the third instead of the 5th of the month

FAD 27.2

Answer 39

B. The patient is sleeping more than usual
C. There is a pink coloration to the skin

Question 40

The nurse understands that oxygen therapy for a patient with COPD requires close monitoring because of which of the following?

A. Hypoxic respiratory drive
B. Hypercapnic respiratory drive
C. Acidotic respiratory drive
D. Alkalotic respiratory drive

FAD 27.3

Answer 40

A. Hypoxic respiratory drive

Question 41

The pulmonary edema associated with ARDS is caused by ?

A. Increased permeability of the ACM
B. Right ventricular failure with pulmonary hypertension
C. Left ventricular failure due to poor oxygenation
D. Fluid overload related to resuscitation in the first phase

FAD27.4

Answer 41

A. Increased permeability of the ACM

Question 42

The ED nurse is assessing a client who was sustained a blunt injury to the chest wall. Which findings indicates the presence of a pneumothorax in this client ?

A. A low respiratory rate
B. Diminished breath sounds
C. The presences of barrel chest
D. A sucking sound at the site of injury

Nclex 625

Answer 42

B. Diminished breath sounds

Question 43

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? SATA

A. Low arterial PC02 levels
B. A hyper-inflated chest noted on Chest X-ray
C. Decreased oxygen saturation w/mild exercise
D. A widened diaphragm noted on the chest X-ray
E. Pulmonary function tests that demonstrate increased vital capacity

nclex 626

Answer 43

B. A hyper-inflated chest noted on Chest X-ray
C. Decreased oxygen saturation w/mild exercise

Question 44

The nurse instructs a client to use the purse lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing the nurse determines that the client understands that the client states that the primary purpose of the purse live breathing is to promote, which outcome?

A. Promote oxygen intake
B. Strengthen the diaphragm
C. Strengthen the intercostal muscles
D. Promote carbon dioxide elimination

Answer 44

D. Promote carbon dioxide elimination

Question 45

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding if noted in the client should be reported immediately to the HCP?

A. Dry cough
B. Hematuria
C. Bronchospasm
D. Blood- streaked sputum

Answer 45

C. Bronchospasm

Question 46

The nurse is preparing to suction as client via a tracheostomy tube. The nurse should plan to limit suctioning time to a maximum of which period time?

A. 5 sec
B. 10 sec
C. 30 sec
D. 60 sec

Answer 46

B. 10 sec

Question 47

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure; the nurse notes on the monitor that the heart rate is decreasing. Which nurse intervention is appropriate?

A. Continue to suction
B. Notify the HCP immediately
C. Stop the procedure and reoxygenate the client
D. Ensure that the suctioning is limited to 15 sec

Answer 47

C. Stop the procedure and reoxygenate the client

Question 48

The nurse is assessing the respiratory status of a client who was suffered a fractured rib. The nurse should expect to note which findings?

A. Slow , deep respirations
B. Rapid, deep respirations
C. Paradoxical respiration
D. Pain, especially with inspiration

Answer 48

D. Pain, especially with inspiration

Question 49

A client with a chest injury suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest ?

A. Cyanosis
B. Hypotension
C. Paradoxical chest movement
D. Dyspnea especially on exhalation

Answer 49

C. Paradoxical chest movement

Question 50

Client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse notes the client when the high-pressure alarm on the ventilator sounds and knows that the client has absence of breath sounds in the right upper lobe of the lung, the nurse immediately assesses for other signs of which condition?

A. Right pneumothorax
B. Pulmonary embolism
C. Displaced endotracheal tube
D. Acute respiratory distress syndrome

Answer 50

A. Right pneumothorax

Question 51

A nurse is assessing a client with multiple trauma who is t risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

A. Bilateral wheezing
B. Inspiratory crackles
C. Intercostal retractions
D. Increased respiratory rate

Answer 51

D. Increased respiratory rate

Question 52

The nurse is discussing the technique of chest physiotherapy and post drainage respiratory treatments to a client having expectoration problems because of chronic tenacious mucous production in the lower airway. The nurse explains that after the client position for drainage, the nurse will perform which action to help loosen secretion.?

A. Palpation and clubbing
B. Percussion and vibration
C. Hyper-oxygenation and suctioning
D. Administer a bronchodilator and monitor peak flow

Answer 52

B. Percussion and vibration

Question 53

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported ?

A. Hot, flushed feeling
B. Sudden chills and fever
C. Chest pain that occurs suddenly
D. Dyspnea when deep breaths are taken

Answer 53

C. Chest pain that occurs suddenly

Question 54

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

A. Face tent
B. Venturi mask
C. Aerosol mask
D. Tracheostomy collar

Answer 54

B. Venturi mask

Question 55

The nurse is instructing a hospitalized client with a diagnosis of of emphysema about measures that will enhance the effectiveness of breathing during dyspnea periods. Which position should the nurse instruct the client to assume?

A. Sitting up in bed
B. Side-lying in bed
C. Sitting in a recliner chair
D. Sitting up and leaning on an over bed table

Answer 55

D. Sitting up and leaning on an over bed table

Question 56

The low pressure alarm sounds on a ventilator. The nurse assesses the client, and then attempts to determine the cause of the alarm if unsuccessful in determining the cause of the learn, the nurse should take what initial action?

A. Administer oxygen
B. Check the clients vital signs
C. Ventilate the client manually
D. Start cardio pulmonary resuscitation

Answer 56

C. Ventilate the client manually