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Physiological Adaptation

NCLEX Respiratory Practice Questions

Quick answer

Respiratory questions on the NCLEX test whether you can spot a client who is about to stop moving air and whether you know the first move when it happens. They fall under Physiological Adaptation, which is 11 to 17 percent of the exam, and airway and breathing problems are a large slice of that section because they are the fastest way a client dies.

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Here is the pattern you will see over and over in this section: a client with a chronic lung problem, a piece of equipment attached to them, and one finding that has quietly changed. Your job is to decide if that finding is expected or dangerous, and what you do about it in the next sixty seconds. The trap that catches most students is the "quiet" client. A wheezing asthmatic sounds scary, so students pick them as the priority, while the asthmatic whose chest has gone silent is the one who is actually about to arrest. The same thing happens with chest tubes. Gentle bubbling that students want to report is often normal, and the absence of fluctuation that they ignore is often the real problem. Learn what normal looks like for each device and each disease and the abnormal findings jump off the page.

Practice questions

1

A client with COPD is admitted with pneumonia. Oxygen saturation is 86 percent on room air, and the client is alert but short of breath. The provider orders oxygen by nasal cannula. Which target saturation should the nurse titrate the oxygen to?

  1. A95 to 100 percent
  2. B92 to 96 percent
  3. C88 to 92 percent
  4. D80 to 85 percent
Show answer

Answer: C

Clients with COPD who retain carbon dioxide are titrated to a saturation of 88 to 92 percent. This treats the hypoxemia without pushing the oxygen level high enough to blunt the respiratory drive or worsen ventilation and perfusion mismatch.

Why the others are wrong

Targets of 92 to 96 or 95 to 100 percent are fine for most clients but can cause carbon dioxide retention and drowsiness in a chronic retainer. A target of 80 to 85 percent leaves the client dangerously hypoxic and is never an acceptable goal.

2

The nurse is caring for four clients on a medical unit. Which client should the nurse assess first?

  1. AA client with asthma who is wheezing loudly in both lung fields and speaking in short phrases
  2. BA client with asthma who was wheezing an hour ago and now has no audible breath sounds and is drowsy
  3. CA client with COPD who has a barrel chest and a saturation of 90 percent on 2 liters
  4. DA client with pneumonia who has a temperature of 101.8 degrees Fahrenheit and a productive cough
Show answer

Answer: B

A "silent chest" in an asthmatic means so little air is moving that there is nothing left to wheeze. Combined with drowsiness, this is impending respiratory failure, and the nurse needs to be at that bedside now with the rapid response team on the way.

Why the others are wrong

Loud wheezing with short phrases is a moderate attack that still needs treatment, but the client is moving air. A saturation of 90 percent on 2 liters is within the expected range for COPD. Fever with a productive cough is expected with pneumonia and is not an airway emergency.

3

A client has a chest tube connected to a water seal drainage system after a spontaneous pneumothorax. The nurse notes intermittent bubbling in the water seal chamber when the client coughs and exhales. What is the nurse's best action?

  1. AClamp the chest tube and notify the provider
  2. BCheck all connections for an air leak
  3. CDocument the finding as expected
  4. DReplace the drainage system
Show answer

Answer: C

Intermittent bubbling in the water seal chamber during exhalation or coughing means air is leaving the pleural space, which is exactly what the tube is there to do. It is expected while the pneumothorax is still resolving.

Why the others are wrong

Continuous bubbling, not intermittent, is the sign of an air leak that needs the connections checked. Clamping a chest tube with an unresolved pneumothorax can cause a tension pneumothorax. There is nothing wrong with the system, so replacing it is unnecessary.

4

While turning a client with a chest tube, the tubing becomes disconnected from the drainage system and the end falls onto the floor. What should the nurse do first?

  1. APlace the end of the tubing in a container of sterile water
  2. BClamp the chest tube near the insertion site
  3. CReconnect the tubing to the drainage system
  4. DApply an occlusive dressing over the insertion site
Show answer

Answer: A

Putting the open end of the tubing into sterile water creates a temporary water seal so air cannot enter the pleural space while a new sterile system is set up. The nurse then calls for help and connects a new system.

Why the others are wrong

Clamping traps air and pressure in the chest and can cause a tension pneumothorax. Reconnecting tubing that has touched the floor contaminates the system. An occlusive dressing is the response when the tube itself is pulled out of the chest, not when the tubing disconnects.

5

A client is 2 days postoperative after hip replacement surgery. The client suddenly reports sharp chest pain and feels anxious. Respirations are 32 per minute, pulse is 118, and saturation has dropped to 87 percent. What action should the nurse take first?

  1. AObtain a 12-lead ECG
  2. BAdminister the ordered subcutaneous enoxaparin
  3. CRaise the head of the bed and apply oxygen
  4. DPrepare the client for a CT angiogram
Show answer

Answer: C

Sudden chest pain, tachypnea, tachycardia, anxiety and a saturation drop in a postoperative orthopedic client point to a pulmonary embolism. The first nursing action is to sit the client upright and start oxygen, then notify the provider and stay with the client.

Why the others are wrong

An ECG and a CT angiogram are part of the workup, but they come after the client is oxygenated and the rapid response is called. Enoxaparin is a prophylactic dose and will not treat an embolism that has already formed; the provider will order therapeutic anticoagulation.

6

A client with sepsis develops acute respiratory distress syndrome. The client is intubated and receiving 80 percent oxygen with positive end-expiratory pressure. Which finding most clearly indicates the lungs are not responding to treatment?

  1. AArterial oxygen pressure of 55 mm Hg despite the high oxygen concentration
  2. BBilateral crackles on auscultation
  3. CThick white secretions when suctioned
  4. DHeart rate of 102 beats per minute
Show answer

Answer: A

The hallmark of ARDS is refractory hypoxemia: the arterial oxygen level stays low no matter how much oxygen is delivered because the alveoli are flooded and stiff. A PaO2 of 55 on 80 percent oxygen shows the ventilator settings are not achieving adequate oxygenation and the provider needs to adjust the plan.

Why the others are wrong

Crackles and secretions are expected findings in ARDS and do not by themselves show failure to respond. A heart rate of 102 is mild tachycardia and is common in a septic client.

7

The nurse is suctioning a client with a tracheostomy. Which action by the nurse is correct?

  1. AApply suction while inserting the catheter to clear secretions on the way in
  2. BLimit each suction pass to no more than 10 to 15 seconds
  3. CInstill 10 mL of normal saline into the tracheostomy before each pass
  4. DSuction continuously for 30 seconds to clear the airway completely
Show answer

Answer: B

Each pass is limited to 10 to 15 seconds because suction removes oxygen along with secretions, and the client should be hyperoxygenated with 100 percent oxygen before and between passes. Suction is applied only while withdrawing the catheter, with a twisting motion.

Why the others are wrong

Applying suction on the way in damages the mucosa and strips oxygen from the airway. Routine saline instillation is no longer recommended because it pushes bacteria deeper and does not thin secretions. A 30 second pass causes hypoxia, bradycardia and arrhythmias.

8

A client on a mechanical ventilator has the high pressure alarm sounding. The nurse enters the room and sees the client coughing and biting the endotracheal tube. What should the nurse do first?

  1. ASilence the alarm and increase the tidal volume
  2. BCheck the ventilator tubing for a disconnection
  3. CAssess the client and suction the airway if secretions are present
  4. DCall respiratory therapy to reset the alarm limits
Show answer

Answer: C

A high pressure alarm means the ventilator is meeting resistance: secretions, biting, coughing, kinked tubing or bronchospasm. The nurse assesses the client, clears the airway and places a bite block if needed. If the cause cannot be found quickly, the client is bagged by hand until it is.

Why the others are wrong

Increasing tidal volume into a blocked airway raises the risk of barotrauma. A disconnection triggers the low pressure alarm, not the high. Resetting alarm limits hides the problem instead of fixing it.

9

A client with a history of emphysema is drowsy and difficult to arouse. Arterial blood gas results are pH 7.28, PaCO2 62 mm Hg, HCO3 27 mEq/L, PaO2 58 mm Hg. How should the nurse interpret these results?

  1. AMetabolic acidosis, uncompensated
  2. BRespiratory acidosis, partially compensated
  3. CRespiratory alkalosis, fully compensated
  4. DMetabolic alkalosis, partially compensated
Show answer

Answer: B

The pH is below 7.35, so this is acidosis. The PaCO2 is high at 62, which matches the acidic pH, so the cause is respiratory. The bicarbonate has risen above 26 as the kidneys try to buffer, but the pH is still abnormal, so compensation is partial. The drowsiness is carbon dioxide narcosis.

Why the others are wrong

In metabolic acidosis the bicarbonate would be low, not high. Respiratory alkalosis would show a low PaCO2 and a pH above 7.45. Metabolic alkalosis would have a high bicarbonate with a high pH, and the PaCO2 here is the primary problem.

10

A client with suspected pulmonary tuberculosis is admitted to the unit. The nurse is reviewing isolation requirements with a new graduate nurse. Which statement by the new graduate shows correct understanding?

  1. A"I will wear a surgical mask when I go in, since TB is spread by droplets."
  2. B"The client needs a private room with the door closed and negative air pressure, and I will wear a fitted N95 respirator."
  3. C"The client can share a room with another client who has pneumonia if both wear masks."
  4. D"I only need the N95 if I am within 3 feet of the client while they are coughing."
Show answer

Answer: B

Tuberculosis is spread by airborne droplet nuclei that stay suspended in the air, so the client is placed on airborne precautions: a private negative pressure room with the door closed and at least 6 to 12 air exchanges per hour, and every person entering wears a fit tested N95 respirator.

Why the others are wrong

A surgical mask does not filter airborne particles and is what the client, not the nurse, wears during transport. TB clients are never cohorted with clients who have a different infection. The N95 is worn the entire time the nurse is in the room, regardless of distance.

Quick tips

  • Position tells you everything. Pulmonary embolism, asthma, pneumothorax and pulmonary edema all start with "sit the client up and give oxygen." After a pneumonectomy, lie the client on the operated side so the remaining lung can expand. After a lobectomy or wedge resection, the operated side goes up.
  • Chest tube rules fit on one line: tidaling in the water seal is good, intermittent bubbling in the water seal is expected, continuous bubbling is a leak, and clamping is only done briefly on a provider's order to check for leaks or to change the system. Keep the system below the chest and never strip the tubing.
  • For ventilator alarms, think high equals obstruction (secretions, biting, kinks, coughing) and low equals leak or disconnection. Either way, if you cannot fix it in seconds, disconnect and bag the client with 100 percent oxygen.
  • ABGs in three steps: look at the pH for acid or base, find which of PaCO2 or HCO3 moves in the same direction as the problem to name it respiratory or metabolic, then check whether the other value has shifted to decide on compensation. Memorize the normals: pH 7.35 to 7.45, PaCO2 35 to 45, HCO3 22 to 26.
  • Precautions are tested with equipment. Airborne (TB, measles, varicella) means N95 and negative pressure. Droplet (influenza, pertussis, meningococcal) means a surgical mask within 3 feet. If a question offers a surgical mask for TB, it is wrong.

Related topics

FAQ

How many respiratory questions are on the NCLEX?

There is no fixed number. Respiratory content is tested inside Physiological Adaptation (11 to 17 percent) and also shows up in Reduction of Risk Potential and Pharmacology, so expect roughly 8 to 15 questions on a typical exam that touch the lungs or airway in some way.

What is the first action for a pulmonary embolism on the NCLEX?

Raise the head of the bed, apply oxygen, and call for help while staying with the client. The exam wants the nursing action you can do yourself in the first minute, not the diagnostic test or the medication that needs a provider's order.

Do I need to memorize ABG values for the NCLEX?

Yes, at least the three normal ranges: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg and HCO3 22 to 26 mEq/L. Most ABG questions give you the numbers and ask you to name the imbalance or pick the client who matches it, so interpretation matters more than recalling the ranges from memory.

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