RESPIRATORY NCLEX EXAM.
COMPREHENSIVE TEST BANK WITH ACTUAL
QUESTIONS WITH CORRECT VERIFIED
ANSWERS. ALREADY GRADED A+
The nurse assesses a patient with shortness of breath for
evidence of long-standing hypoxemia by inspecting: A.
Chest excursion B. Spinal curvatures C. The respiratory
pattern D. The fingernail and its base - ✔ ANSWER ✔ D.
The fingernail and its base Clubbing, a sign of long-standing
hypoxemia, is evidenced by an increase in the angle
between the base of the nail and the fingernail to 180
degrees or more, usually accompanied by an increase in the
depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient admitted to the hospital
with pneumonia. Upon assessment, the nurse notes a
temperature of 101.4° F, a productive cough with yellow
sputum and a respiratory rate of 20. Which of the following
nursing diagnosis is most appropriate based upon this
assessment? A. Hyperthermia related to infectious illness B.
,Ineffective thermoregulation related to chilling C. Ineffective
breathing pattern related to pneumonia D. Ineffective
airway clearance related to thick secretions - ✔ ANSWER
✔ A. Hyperthermia related to infectious illness Because the
patient has spiked a temperature and has a diagnosis of
pneumonia, the logical nursing diagnosis is hyperthermia
related to infectious illness. There is no evidence of a chill,
and her breathing pattern is within normal limits at 20
breaths per minute. There is no evidence of ineffective
airway clearance from the information given because the
patient is expectorating sputum.
Which of the following physical assessment findings in a
patient with pneumonia best supports the nursing diagnosis
of ineffective airway clearance? A. Oxygen saturation of
85% B. Respiratory rate of 28 C. Presence of greenish
sputum D. Basilar crackles - ✔ ANSWER ✔ D. Basilar
crackles The presence of adventitious breath sounds
indicates that there is accumulation of secretions in the
lower airways. This would be consistent with a nursing
diagnosis of ineffective airway clearance because the
patient is retaining secretions.
, Which of the following clinical manifestations would the
nurse expect to find during assessment of a patient
admitted with pneumococcal pneumonia? A.
Hyperresonance on percussion B. Fine crackles in all lobes
on auscultation C. Increased vocal fremitus on palpation D.
Vesicular breath sounds in all lobes - ✔ ANSWER ✔ C.
Increased vocal fremitus on palpation. A typical physical
examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Other signs of
pulmonary consolidation include dullness to percussion,
bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest
priority in helping a patient expectorate thick secretions
related to pneumonia? A. Humidify the oxygen as able B.
Increase fluid intake to 3L/day if tolerated. C. Administer
cough suppressant q4hr. D. Teach patient to splint the
affected area. - ✔ ANSWER ✔ B. Increase fluid intake to
3L/day if tolerated. Although several interventions may help
the patient expectorate mucus, the highest priority should
be on increasing fluid intake, which will liquefy the
COMPREHENSIVE TEST BANK WITH ACTUAL
QUESTIONS WITH CORRECT VERIFIED
ANSWERS. ALREADY GRADED A+
The nurse assesses a patient with shortness of breath for
evidence of long-standing hypoxemia by inspecting: A.
Chest excursion B. Spinal curvatures C. The respiratory
pattern D. The fingernail and its base - ✔ ANSWER ✔ D.
The fingernail and its base Clubbing, a sign of long-standing
hypoxemia, is evidenced by an increase in the angle
between the base of the nail and the fingernail to 180
degrees or more, usually accompanied by an increase in the
depth, bulk, and sponginess of the end of the finger.
The nurse is caring for a patient admitted to the hospital
with pneumonia. Upon assessment, the nurse notes a
temperature of 101.4° F, a productive cough with yellow
sputum and a respiratory rate of 20. Which of the following
nursing diagnosis is most appropriate based upon this
assessment? A. Hyperthermia related to infectious illness B.
,Ineffective thermoregulation related to chilling C. Ineffective
breathing pattern related to pneumonia D. Ineffective
airway clearance related to thick secretions - ✔ ANSWER
✔ A. Hyperthermia related to infectious illness Because the
patient has spiked a temperature and has a diagnosis of
pneumonia, the logical nursing diagnosis is hyperthermia
related to infectious illness. There is no evidence of a chill,
and her breathing pattern is within normal limits at 20
breaths per minute. There is no evidence of ineffective
airway clearance from the information given because the
patient is expectorating sputum.
Which of the following physical assessment findings in a
patient with pneumonia best supports the nursing diagnosis
of ineffective airway clearance? A. Oxygen saturation of
85% B. Respiratory rate of 28 C. Presence of greenish
sputum D. Basilar crackles - ✔ ANSWER ✔ D. Basilar
crackles The presence of adventitious breath sounds
indicates that there is accumulation of secretions in the
lower airways. This would be consistent with a nursing
diagnosis of ineffective airway clearance because the
patient is retaining secretions.
, Which of the following clinical manifestations would the
nurse expect to find during assessment of a patient
admitted with pneumococcal pneumonia? A.
Hyperresonance on percussion B. Fine crackles in all lobes
on auscultation C. Increased vocal fremitus on palpation D.
Vesicular breath sounds in all lobes - ✔ ANSWER ✔ C.
Increased vocal fremitus on palpation. A typical physical
examination finding for a patient with pneumonia is
increased vocal fremitus on palpation. Other signs of
pulmonary consolidation include dullness to percussion,
bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest
priority in helping a patient expectorate thick secretions
related to pneumonia? A. Humidify the oxygen as able B.
Increase fluid intake to 3L/day if tolerated. C. Administer
cough suppressant q4hr. D. Teach patient to splint the
affected area. - ✔ ANSWER ✔ B. Increase fluid intake to
3L/day if tolerated. Although several interventions may help
the patient expectorate mucus, the highest priority should
be on increasing fluid intake, which will liquefy the
