NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
MULTIPLE CHOICE
1. A patient with acute shortness of breath is admitted to the hospital. Which action should
the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests.
ANS: B
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining a
comprehensive health history or full physical examination is unnecessary until the acute
distress has resolved. Brief questioning and a focused physical assessment should be done
rapidly to help determine the cause of the distress and suggest treatment. Checking for
allergies is important, but it is not appropriate to complete the entire admission database at
this time. The initial respiratory assessment must be completed before any diagnostic tests
or interventions can be ordered.
DIF: Cognitive Level: Apply (application) REF: 459
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler’s position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to
collect at the lung bases, and expands the intercostal space so that access to the pleural
space is easier. The other positions would increase the work of breathing for the patient
and make it more difficult for the health care provider performing the thoracentesis.
DIF: Cognitive Level: Apply (application) REF: 471
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85
,NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
– mm Hg; HCO3 18 mEq/L. The nurse would
expect which finding?
a. Intercostal retractions c. Low oxygen saturation (SpO2)
b. Kussmaul respirations d. Decreased venous O2 pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for
metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis.
Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure
would not be caused by acidosis.
DIF: Cognitive Level: Apply (application) REF: 467
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse document this
finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-
pitched sounds. They can be heard during the expiratory or inspiratory phase of the
respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction
rubs are grating sounds that are usually heard during both inspiration and expiration.
DIF: Cognitive Level: Apply (application) REF: 468
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse palpates the posterior chest while the patient says “99” and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for
vibration when the patient repeats a word or phrase such as “99.” After noting absent
fremitus, the nurse should then auscultate the lungs to assess for the presence or absence
of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The
,NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial
secretions, and pleural effusion. Turning, coughing, and deep breathing is an
appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds.
Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated
(barrel chest). The anterior of the chest is more difficult to palpate for fremitus because
of the presence of large muscles and breast tissue.
DIF: Cognitive Level: Apply (application) REF: 464
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which
intervention will the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
ANS: C
Risk for aspiration and maintaining an open airway is the priority. Because a local
anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse
should monitor for the return of these reflexes before allowing the patient to take oral
fluids or food. The patient does not need to be on bed rest, and the head of the bed does
not need to be in the high-Fowler’s position.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. The nurse completes a shift assessment on a patient admitted in the early phase of heart
failure. When auscultating the patient’s lungs, which finding would the nurse most
likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high-pitched sounds of short duration heard on inspiration. Course crackles
are a series of long-duration, discontinuous, low-pitched sounds during inspiration.
Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
DIF: Cognitive Level: Apply (application) REF: 468
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
, NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
8. The nurse observes that a patient with respiratory disease experiences a decrease in SpO2
from 93% to 88% while the patient is ambulating. What is the priority action of the
nurse?
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity.
ANS: B
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental
O2 when exercising. The other actions are also important, but the first action should be
to correct the hypoxemia.
DIF: Cognitive Level: Analyze (analysis) REF: 459
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation MSC: NCLEX: Physiological Integrity
9. The nurse teaches a patient about pulmonary spirometry testing. Which statement, if
made by the patient, indicates teaching was effective?
a. “I should use my inhaler right before the test.”
b. “I won’t eat or drink anything 8 hours before the test.”
c. “I will inhale deeply and blow out hard during the test.”
d. “My blood pressure and pulse will be checked every 15 minutes.”
ANS: C
For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as
possible. The other actions are not needed. The administration of inhaled bronchodilators
should be avoided 6 hours before the procedure.
DIF: Cognitive Level: Apply (application) REF: 472
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. The nurse observes a student who is listening to a patient’s lungs. Which action by
the student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth.
ANS: B
Listening only during inspiration indicates the student needs a review of respiratory
assessment skills. At each placement of the stethoscope, listen to at least one cycle of
EXAM QUESTIONS WITH ANSWERS 2023
MULTIPLE CHOICE
1. A patient with acute shortness of breath is admitted to the hospital. Which action should
the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests.
ANS: B
When a patient has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining a
comprehensive health history or full physical examination is unnecessary until the acute
distress has resolved. Brief questioning and a focused physical assessment should be done
rapidly to help determine the cause of the distress and suggest treatment. Checking for
allergies is important, but it is not appropriate to complete the entire admission database at
this time. The initial respiratory assessment must be completed before any diagnostic tests
or interventions can be ordered.
DIF: Cognitive Level: Apply (application) REF: 459
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler’s position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to
collect at the lung bases, and expands the intercostal space so that access to the pleural
space is easier. The other positions would increase the work of breathing for the patient
and make it more difficult for the health care provider performing the thoracentesis.
DIF: Cognitive Level: Apply (application) REF: 471
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. A diabetic patient’s arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85
,NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
– mm Hg; HCO3 18 mEq/L. The nurse would
expect which finding?
a. Intercostal retractions c. Low oxygen saturation (SpO2)
b. Kussmaul respirations d. Decreased venous O2 pressure
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism for
metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis.
Intercostal retractions, a low oxygen saturation rate, and a decrease in venous O2 pressure
would not be caused by acidosis.
DIF: Cognitive Level: Apply (application) REF: 467
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. On auscultation of a patient’s lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse document this
finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: A
Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-
pitched sounds. They can be heard during the expiratory or inspiratory phase of the
respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction
rubs are grating sounds that are usually heard during both inspiration and expiration.
DIF: Cognitive Level: Apply (application) REF: 468
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse palpates the posterior chest while the patient says “99” and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally.
ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for
vibration when the patient repeats a word or phrase such as “99.” After noting absent
fremitus, the nurse should then auscultate the lungs to assess for the presence or absence
of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The
,NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial
secretions, and pleural effusion. Turning, coughing, and deep breathing is an
appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds.
Fremitus is decreased if the hand is farther from the lung or the lung is hyperinflated
(barrel chest). The anterior of the chest is more difficult to palpate for fremitus because
of the presence of large muscles and breast tissue.
DIF: Cognitive Level: Apply (application) REF: 464
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
6. A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which
intervention will the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees.
ANS: C
Risk for aspiration and maintaining an open airway is the priority. Because a local
anesthetic is used to suppress the gag and cough reflexes during bronchoscopy, the nurse
should monitor for the return of these reflexes before allowing the patient to take oral
fluids or food. The patient does not need to be on bed rest, and the head of the bed does
not need to be in the high-Fowler’s position.
DIF: Cognitive Level: Apply (application) REF: 470
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. The nurse completes a shift assessment on a patient admitted in the early phase of heart
failure. When auscultating the patient’s lungs, which finding would the nurse most
likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
ANS: C
Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are
discontinuous, high-pitched sounds of short duration heard on inspiration. Course crackles
are a series of long-duration, discontinuous, low-pitched sounds during inspiration.
Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
DIF: Cognitive Level: Apply (application) REF: 468
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
, NURS MED SURGE-ASSESSMENT OF RESPIRATORY SYSTEM
EXAM QUESTIONS WITH ANSWERS 2023
8. The nurse observes that a patient with respiratory disease experiences a decrease in SpO2
from 93% to 88% while the patient is ambulating. What is the priority action of the
nurse?
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity.
ANS: B
The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental
O2 when exercising. The other actions are also important, but the first action should be
to correct the hypoxemia.
DIF: Cognitive Level: Analyze (analysis) REF: 459
OBJ: Special Questions: Prioritization TOP: Nursing Process:
Implementation MSC: NCLEX: Physiological Integrity
9. The nurse teaches a patient about pulmonary spirometry testing. Which statement, if
made by the patient, indicates teaching was effective?
a. “I should use my inhaler right before the test.”
b. “I won’t eat or drink anything 8 hours before the test.”
c. “I will inhale deeply and blow out hard during the test.”
d. “My blood pressure and pulse will be checked every 15 minutes.”
ANS: C
For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as
possible. The other actions are not needed. The administration of inhaled bronchodilators
should be avoided 6 hours before the procedure.
DIF: Cognitive Level: Apply (application) REF: 472
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
10. The nurse observes a student who is listening to a patient’s lungs. Which action by
the student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth.
ANS: B
Listening only during inspiration indicates the student needs a review of respiratory
assessment skills. At each placement of the stethoscope, listen to at least one cycle of
