NSE 103 - WEEKS 6-7 EXAM QUESTIONS WITH CORRECT ANSWERS LATEST UPDATE 2026

NSE 103 - WEEKS 6-7 EXAM QUESTIONS WITH CORRECT ANSWERS LATEST UPDATE 2026 Respiratory system - Answers composed of upper and lower tract upper tract: nasal cavity and paranasal sinus, pharynx and larynx lower: trachea, bronchi, respiratory units, lungs (3 R and 2L lobes), pleural membranes & pleural cavity, pulm artery/vein, diaphragm hypoxemia - Answers low lvls of o2 in blood hypoxia - Answers low lvls of o2 in tissues and organs hypercapnia - Answers high blood lvls of co2 subjective assessment of resp system includes - Answers asking questions about client's health and symptoms that occur bc of pathologies that affect upper and lower tract common problems assoc w respiratory system - Answers sinusitis nasal polyps asthma pneumonia cancer emphysema cystic fibrosis copd dyspnea - Answers difficulty breathing / shortness of breath what is dyspnea often accompanied w - Answers tachycardia (rapid RR) why may older adults sometimes experience mild shortness of breath - Answers bc of anatomical lung changes including decreased muscle mass, lung elasticity and increased lung rigidity client showing signs of clinical deterioration and low b.p, raise or lower head of bed? - Answers lower head to increase amt of blood returning to heart how can you recognize cues that indicate clinical deterioration - Answers conduct a primary survey Assess the client's respiration rate, work of breathing, oxygen saturation, and then pulse, blood pressure, and temperature, followed by auscultation of lungs. tussis - Answers coughing can be wet or dry wet coughs - Answers produce expectorate (mucus) mucus can be thin or thick, and can be clear, yellow, green, pink-tinged hemoptysis - Answers bloody expectorate from cough what should you consider when providing care to a pt with a cough - Answers consider the cough transmissible wear correct ppe (mask, eye protection) chest and nasal congestion - Answers accumulation of mucus in chest/lungs may be assoc w coughing, runny nose, sneezing sinus pain/pressure - Answers sensation of facial pain or pressure in sinuses commonly assoc w inflammation, infection, blockage of sinuses t or f location of sinus pain is important - Answers true location can potentially help determine cause and sinuses affected wheezing - Answers whistling sound or noisy breathing assoc w inspiration and/or expiration what is wheezing commonly associated w - Answers narrowing of airways inflammation bronchospasm what is essential to rule out first in a pt that is wheezing - Answers rule out anaphylaxis first bc it is life threatening and assess if they have been exposed to allergies administer epi if suspected what is the best position to support a client showing signs of clinical deterioration - Answers supine w bed of head lowered respiratory cues that require urgent intervention - Answers cyanosis/pallor sudden onset of confusion severe shortness of breath or wheezing chest pain can be related to hypoxia or clinical deterioration objective assessment of respiratory system includes - Answers brief scan of resp system inspection and palpation of nose and sinuses IAPP of posterior and lat thorax (inspect, auscultate, palpate, percuss) best position to assess lungs - Answers seated or high fowlers w client looking ahead side lying if they cannot sit up assessment of lateral thorax and posterior thorax involves - Answers assessing from the shoulders and the axillary area down to the bottom of the rib cage assessment of anterior thorax includes - Answers assessing from the lung apices (just above the clavicles) down to the bases (at bottom of the rib cage). brief scan - Answers involves inspection of client's breathing and elements of primary survey helps you quickly recognize cues of clinical deterioration and respiratory distess steps of brief scan - Answers in order of importance: airway patency presence of breathing and resp rate work of breathing and signs of distress o2 sat lvl of consciousness, facial expressions, body colour changes assessing airway patency - Answers determine whether there is an open airway or presence of obstructive airway symptoms first lvl priority of care symptoms of obstructed airway - Answers secretions (mucus, blood) snoring stridor difficulty breathing coughing drooling stridor - Answers A high pitched sound generated from partially obstructed air flow in the upper airway. assess presence of breathing and rr - Answers assess presence of breathing and eupnea (normal automatic breathing w reg rhythm) apnea - Answers cessation of breathing permanently or intermittently can lead to hypoxia if breathing is regular - Answers count for 30 seconds count for 1 min if irregular Newborn to one month resp rates - Answers 30 - 60 One month to one year - Answers 26 - 60 1 to 10 years - Answers 14 - 50 11 to 18 years - Answers 12 - 22 adult and older adult rr - Answers 10 - 20 assess work of breathing and resp distress - Answers is breathing silent, noisy, wheezing, stridor do you observe nasal flaring, use of accessory muscles, intercostal tugging or abnormal breathing agonal breathing - Answers irregular breathing rhythm w gasping and is a sign that person is near death signs of respiratory distress - Answers tripod position, nasal flaring, intercostal tugging assess o2 sat - Answers should be 97-100 common for older adults to have o2 of 95-97 children should not be under 97 considerations before taking o2 sat - Answers remove nail polish low perfusion states can affect o2 sats, use pulse oximeter on ear or forehead assess lvl of consciousness, facial expression, body position for signs of resp distress - Answers observe for altered lvl of consciousness or orientation wide eyes, grimacing tripod position/hunched over/unable to sit up assess colour changes (and nails for clubbing & cap refill) - Answers observe for signs of pallor or cyanosis in lips, mucous membranes, fingernails, conjunctiva can indicate hypoxemia in dark skin, cyanosis can appear as - Answers grey/white shade around lips conjunctiva can appear as grey/bluish in light skin, cyanosis can appear as - Answers dusky blue / purple shade clubbed fingernails - Answers related to conditions of chronic hypoxia cause nail angle to flatten to 180 degrees or more, nail beds soften and spongy assess index finger, or thumb if early clubbing normal nail angle - Answers 160 degrees normal cap refill - Answers within 3 seconds or less more than 3 seconds = sluggish return, suggests issues with oxygenated blood perfusion abnormal findings from objective respiratory assessment - Answers Stridor present nasal flaring and intercostal tugging pallor noted around lips Oxygen saturations 91% Slow capillary refill at 4-5 seconds. if airway is not patent in pt in resp distress - Answers try to open the airway with a head-tilt-chin-lift and inspect the mouth and nose for obstructions. if you suspect client choking - Answers place them in a high fowlers position encourage them to cough and clear their airway may need to suction the oral cavity and airway, lower o2 sats (88 - 92) are acceptable in those with - Answers copd nose inspection abnormal findings - Answers Bright red nasal mucosa with purulent discharge palpation of sinuses - Answers one at a time use circular motion begin w frontal sinuses inferior to eyebrows over bony prominence Then maxillary sinuses inferior to the zygomatic bone slightly lateral to the nose. assess for pain palpation of nose for airflow / patency - Answers Occlude one naris at a time while placing your index finger over the outside of the nose/nasal wing Ask the client to take a deep and quick inhalation in through the nose client should be able to breathe in w no obstructions abnormal findings of nose palpation - Answers Left frontal sinus pain 6/10." t or f: deviated septum requires urgent intervention - Answers false deviated septums are common no action required unless it affects clients breathing abnormal findings of nose/sinus that require action - Answers cutaneous lesions on nose / open sore that has developed w no physical trauma and has not healed (4-6 wks) sinus pain if chest expansion is asymmetrical - Answers can happen when one lung cant expand due to conditions that involve inflammation and air between the lungs and chest wall (i.e., pneumothorax) or partial or complete collapse of the alveoli (i.e., atelectasis) the thorax shortens while the costal angle widens to accommodate the enlarging uterus in what population - Answers pregnant women normal finding anteroposterior to transverse diameter ratio - Answers 1:2 ratio of 1:1 can indicate - Answers conditions that give rise to hyperinflated lungs (e.g., emphysema). or present in kids younger than 2 ribs should be - Answers downward sloping vertical when auscultating post and lat thorax, assess for - Answers Air entry quality and equality quality: good, decreased, absent equality: air entry is equal bilaterally bronchovesicular breath sounds - Answers moderate in loudness inspiration is equal to the expiration phase heard on the upper thorax close to the vertebrae and near the bronchi vesicular breath sounds - Answers quiet and low-pitched inspiration is longer than the expiration phase heard in the periphery of the lung fields and near the smaller airways in an older child and adult. not often heard in kids under 2-3 abnormal lung sounds - Answers adventitious sounds: wheezes, stridor, crackles when do wheezes occur - Answers when there is bronchoconstriction Higher pitch = increased bronchoconstriction Lower pitch = decreased bronchoconstriction. often described as mild, moderate, or severe. stridor occurs when - Answers when the upper airways are partially obstructed, and have congenital, infectious, or trauma-related causes. continuous and high-pitched. commonly heard on inspiration, it can be heard on expiration too. usually associated with other signs of respiratory distress and requires immediate response. crackles - Answers heard in the lungs when there is an accumulation of fluid (e.g., mucus), such as with pneumonia. sound like an interrupted popping and even a bubbling noise described as fine, moderate, or coarse crackles Mild crackles are typically heard in the bases because fluid accumulation in the lungs is affected by gravity. urgent sitn - Answers absent air entry and stridor crepitus - Answers crackling under the skin similar to popping bubble wrap. acute condition related to subcutaneous emphysema in which air shifts out of the lungs and into the subcutaneous tissues as a result of traumatic, surgical, or infectious causes. when do you use ulnar, dorsa, and fingerpads in palpating post thorax - Answers ulnar: tactile fremitus dorsa: temo fingerpads: crepitus normal percussion note in lungs - Answers resonance, which is a low-pitched and hollow sound. With very young children under the age of about 5, hyperresonance is heard abnormal percussion notes - Answers dull or hyperresonance when is percussion not reliable - Answers when a client is overweight or obese because the adipose tissue modifies the normal resonance to a dull note. when would u hear dull sounds, and flat sounds - Answers dull = heart flat = sternum or ribs(bones) costal angle - Answers the angle between the costal margins inferior to the xiphoid process normally 90 degrees abnormal finding of costal angle - Answers angle flattened out occurs with chronic lung conditions associated with hyperinflation of the lungs abnormal findings of anterior thorax may be documented as - Answers Tracheal deviation to the right side. Costal angle 170 degrees, horizontal ribs with a 1:1 anteroposterior to transverse diameter. findings of most concern after inspecting ant thorax - Answers tracheal deviation or assymetrical lung expansion suggestive of decreased ventilation to one side of the lungs possibly caused by pneumothorax, atelectasis, or pleural effusion A client comes to the clinic and states they believe vaccination does more harm than good. What health promotion question should the nurse ask the client? - Answers tell me more about your concern cardiovascular system is important because - Answers responsible for the provision of blood, oxygen, and nutrients to the body's tissues and organs. components of cv system - Answers The heart (two atriums, two ventricles, and four valves). The main vessels (aorta, pulmonary artery, pulmonary vein, and superior and inferior vena cava). The coronary arteries. The carotid arteries and jugular veins common symptoms of cv disease - Answers e pain, dyspnea, arrhythmias, coughing/wheezing, and edema cardiac ischemia - Answers deficit of oxygen rich blood to cardiac muscle commonly caused by atherosclerosis (build up of plaque) and pericarditis cardiac pain - Answers pain associated with the heart and can be described in many ways such as crushing, pressure, squeezing, tightness, and heaviness in the chest. can be referred pain to other parts of body t or f cardiac pain is a critical finding - Answers true, requires immediate action. It is considered a first-level priority of care. You should ask a colleague to notify the physician while you keep the client at rest, assess pulse, blood pressure, and oxygen saturations. arrhythmia - Answers irregular heart rhythms (e.g., atrial fibrillation) or irregular heart rates (e.g., tachycardia, bradycardia). assess apical pulse rate and rhythm and bp Peripheral edema (cardiac related) - Answers swelling that occurs from excess fluid in the tissues. cardiac: usually caused by the heart not pumping adequately and blood backing up causing swelling. what is a related symptom to edema - Answers nocturia sometimes rapid weight gain rapid weight gain can suggest - Answers increased fluid retention heart failure how much weight gain in 24 hours requires immediate action - Answers A 2-3 lb (.9 to 1.3 kg) weight increase in 24 hours what to do in case of angina - Answers Notify the physician/nurse practitioner. Take the client's vital signs: pulse, respirations, blood pressure, and oxygen saturation. Keep the client at rest, preferably lying in bed in case they deteriorate. If you have standing orders in your healthcare setting, you may also apply oxygen, order an electrocardiogram (ECG) and bloodwork, give morphine intravenously, and provide the prescribed/protocol dose nitroglycerin spray. hypertensive crisis - Answers bp 180/110 can lead to mi or stroke