Respiratory Volume 1

The nurse identifies that the movement of oxygen and carbon dioxide between the alveoli and capillaries occurs by which process? A. Perfusion B. Diffusion C. Ventilation D. Transport

Answer – B. Diffusion – Rationale: Diffusion is the passive movement of gases between alveoli and capillaries, driven by concentration gradients, essential for gas exchange.

The term “ventilation” refers to which process? A. The transport of oxygen in the blood B. The mechanical movement of air in and out of the lungs C. The exchange of gases at the capillary membrane D. The circulation of blood through the lungs

Answer – B. The mechanical movement of air in and out of the lungs – Rationale: Ventilation describes the physical act of breathing, using the diaphragm and intercostal muscles.

Pulmonary perfusion is best defined as: A. Air moving into alveoli B. Blood flow through the pulmonary capillaries C. Exchange of gases at the alveolar membrane D. The diffusion of carbon dioxide out of cells

Answer – B. Blood flow through the pulmonary capillaries – Rationale: Perfusion involves the movement of blood through pulmonary vessels to allow gas exchange at the alveolar-capillary junction.

Which statement accurately describes respiration? A. The exchange of oxygen for carbon dioxide within cells B. The act of breathing that includes both inspiration and expiration C. The movement of oxygen through the bloodstream D. The cellular use of oxygen to create ATP

Answer – B. The act of breathing that includes both inspiration and expiration – Rationale: Respiration refers to the overall process of air movement into and out of the lungs during breathing.

The nurse documents “dyspnea” in a patient’s record. Which description supports this finding? A. Periods of no breathing B. Breathing rate less than 10 per minute C. Subjective feeling of shortness of breath D. Increased depth and rate of breathing

Answer – C. Subjective feeling of shortness of breath – Rationale: Dyspnea is the sensation of difficulty or uncomfortable breathing, often reported by the patient.

The nurse observes a patient who becomes short of breath while lying flat but can breathe comfortably when sitting upright. Which term describes this finding? A. Orthopnea B. Apnea C. Bradypnea D. Tachypnea

Answer – A. Orthopnea – Rationale: Orthopnea is difficulty breathing when supine, relieved by sitting up, common in heart failure and pulmonary edema.

A patient seated upright, leaning forward over a bedside table to facilitate easier breathing, is demonstrating which position? A. Fowler’s B. Orthopneic C. Supine D. Lateral

Answer – B. Orthopneic – Rationale: The orthopneic position allows maximal chest expansion and use of accessory muscles, improving oxygenation in respiratory distress.

A respiratory rate of 40 breaths per minute is documented. How should the nurse interpret this finding? A. Eupnea B. Bradypnea C. Tachypnea D. Apnea

Answer – C. Tachypnea – Rationale: Tachypnea refers to abnormally rapid respirations, often seen with fever, anxiety, or hypoxia.

The nurse counts a respiratory rate of 8 breaths per minute. How should this be recorded? A. Eupnea B. Tachypnea C. Bradypnea D. Apnea

Answer – C. Bradypnea – Rationale: Bradypnea indicates a respiratory rate below 10 breaths per minute, often resulting from CNS depression or drug effects.

The nurse observes a patient who has no airflow for more than 15 seconds. What does this represent? A. Orthopnea B. Dyspnea C. Apnea D. Tachypnea

Answer – C. Apnea – Rationale: Apnea is a temporary cessation of breathing lasting 15 seconds or more, requiring prompt assessment and intervention to restore ventilation.

A patient with anemia reports shortness of breath on exertion. The nurse understands this occurs because of which alteration in oxygen transport? A. Decreased oxygen diffusion in alveoli B. Decreased hemoglobin to carry oxygen C. Decreased pulmonary perfusion D. Decreased ventilation rate

Answer – B. Decreased hemoglobin to carry oxygen – Rationale: Oxygen transport depends on hemoglobin

A client with COPD retains carbon dioxide. Which term describes this problem? A. Hyperventilation B. Hypoventilation C. Hypoxia D. Apnea

Answer – B. Hypoventilation – Rationale: Hypoventilation causes CO₂ retention (hypercapnia) because the lungs do not adequately eliminate carbon dioxide.

The nurse identifies which condition as resulting from excessive elimination of carbon dioxide due to rapid breathing? A. Hypoventilation B. Hypoxemia C. Hyperventilation D. Orthopnea

Answer – C. Hyperventilation – Rationale: Hyperventilation increases respiratory rate, blowing off too much CO₂, leading to low carbon dioxide levels (hypocapnia).

The nurse is caring for a client with pulmonary embolism. Which concept is directly impaired by this condition? A. Diffusion B. Perfusion C. Ventilation D. Transport

Answer – B. Perfusion – Rationale: Pulmonary embolism blocks blood flow in the pulmonary circulation, preventing perfusion of alveoli and leading to hypoxemia.

The nurse finds a client with rapid shallow respirations and restlessness. What is the nurse’s first action? A. Encourage deep breathing and assess oxygen saturation B. Increase fluid intake C. Ask about caffeine consumption D. Place the client in a supine position

Answer – A. Encourage deep breathing and assess oxygen saturation – Rationale: Restlessness and tachypnea suggest early hypoxia

The nurse observes a patient who becomes restless and coughs frequently after drinking water. What is the nurse’s next action? A. Encourage more oral fluids B. Auscultate lung sounds and assess swallowing ability C. Administer cough suppressant D. Document as normal

Answer – B. Auscultate lung sounds and assess swallowing ability – Rationale: Restlessness and coughing after eating or drinking may indicate aspiration, which can lead to pneumonia and hypoxia.

When counting respirations in a newborn or child, which action by the nurse is most appropriate? A. Count respirations for 15 seconds and multiply by 4 B. Count for one full minute C. Estimate based on heart rate D. Observe chest expansion only

Answer – B. Count for one full minute – Rationale: Infants and children have irregular respiratory patterns

When teaching parents about safe sleep, the nurse includes which statement? A. Place the baby on the stomach to prevent aspiration B. Side-lying is preferred for better airway drainage C. Always place babies on their backs to sleep D. Keep pillows in the crib for comfort

Answer – C. Always place babies on their backs to sleep – Rationale: The supine position reduces the risk of sudden infant death syndrome (SIDS) by keeping the airway clear.

During a respiratory assessment, the nurse notes the trachea is deviated to the right. What does this finding suggest? A. Normal variation B. Left lung collapse or pneumothorax C. Right-sided atelectasis D. Fluid overload

Answer – B. Left lung collapse or pneumothorax – Rationale: Tracheal deviation toward the unaffected side indicates tension pneumothorax or lung collapse on the opposite side.

The nurse hears fine crackles at the lung bases. What is the most likely cause? A. Air passing through narrowed airways B. Fluid in the alveoli from heart failure or pneumonia C. Large airway secretions D. Airway obstruction

Answer – B. Fluid in the alveoli from heart failure or pneumonia – Rationale: Fine crackles result from fluid or collapsed alveoli opening during inspiration, common in CHF or pneumonia.

The nurse hears wheezing on exhalation. Which condition does this indicate? A. Air moving through narrowed bronchioles B. Fluid in alveoli C. Airway obstruction in trachea D. Secretions in large airways

Answer – A. Air moving through narrowed bronchioles – Rationale: Wheezes are high-pitched musical sounds caused by airway narrowing, seen in asthma or COPD.

While auscultating, the nurse hears low-pitched gurgling sounds that clear with coughing. What are these sounds called? A. Crackles B. Wheezes C. Rhonchi D. Stridor

Answer – C. Rhonchi – Rationale: Rhonchi are coarse sounds caused by secretions in large airways that often clear with coughing, common in bronchitis.

A patient exhibits loud, harsh, crowing sounds during inspiration. What is the nurse’s priority action? A. Reassess in 15 minutes B. Suction the oropharynx C. Notify the provider immediately D. Encourage coughing

Answer – C. Notify the provider immediately – Rationale: Stridor signals upper airway obstruction or anaphylaxis, which is a medical emergency requiring immediate intervention.

The nurse is evaluating a chest x-ray for a patient with shortness of breath. Which finding indicates atelectasis? A. Overinflated lungs B. Collapsed alveoli with reduced air volume C. Air-fluid level D. Air in pleural space

Answer – B. Collapsed alveoli with reduced air volume – Rationale: Atelectasis appears as areas of collapse or opacity due to alveolar deflation, often from immobility or mucus plugs.

The provider orders a chest x-ray for a patient with chest pain and dyspnea. What can this test help identify? A. Only pneumonia B. Atelectasis, infiltrates, effusions, pneumothorax, hemothorax, cardiomegaly C. Pulmonary embolism only D. Heart valve disorders

Answer – B. Atelectasis, infiltrates, effusions, pneumothorax, hemothorax, cardiomegaly – Rationale: A chest x-ray visualizes the lungs and heart structures to identify fluid, air, or enlargement abnormalities.

The nurse explains that a computed tomography (CT) scan is used primarily to: A. Evaluate bone integrity only B. Identify small nodules, tumors, or pulmonary emboli C. Measure perfusion and ventilation ratio D. Visualize vocal cord movement

Answer – B. Identify small nodules, tumors, or pulmonary emboli – Rationale: CT scans provide detailed cross-sectional imaging to detect structural abnormalities and vascular blockages.

A V/Q scan is ordered for a patient with suspected pulmonary embolism. The nurse explains the purpose of this test as: A. Measuring alveolar expansion B. Assessing perfusion and ventilation of the lungs C. Evaluating heart function D. Detecting airway resistance

Answer – B. Assessing perfusion and ventilation of the lungs – Rationale: The ventilation-perfusion (V/Q) scan evaluates how well air and blood flow match within the lungs, useful for detecting PE.

The nurse is preparing a patient for a bronchoscopy. Which teaching point is essential? A. The patient will remain on a clear liquid diet afterward B. NPO 6–8 hours before the procedure C. Encourage deep breathing during the procedure D. Eat immediately after

Answer – B. NPO 6–8 hours before the procedure – Rationale: Bronchoscopy requires NPO status to prevent aspiration during sedation and airway manipulation.

After a bronchoscopy, the nurse’s priority assessment is to: A. Monitor bowel sounds B. Assess for return of gag reflex before oral intake C. Encourage early ambulation D. Check urine output

Answer – B. Assess for return of gag reflex before oral intake – Rationale: Airway reflexes are temporarily suppressed by anesthesia

A thoracentesis is scheduled for a client with pleural effusion. Which statement by the nurse best describes the purpose of the procedure? A. To remove air or fluid from the pleural space B. To visualize the trachea and bronchi C. To obtain arterial blood for gas measurement D. To check cardiac output

Answer – A. To remove air or fluid from the pleural space – Rationale: Thoracentesis is used diagnostically and therapeutically to relieve dyspnea or analyze pleural fluid.

After a thoracentesis, which finding requires immediate nursing action? A. Mild discomfort at the puncture site B. Small amount of serous drainage on dressing C. Sudden shortness of breath and tracheal deviation D. Coughing with deep breaths

Answer – C. Sudden shortness of breath and tracheal deviation – Rationale: These signs suggest a pneumothorax, a possible complication after thoracentesis requiring urgent evaluation.

The nurse recognizes hypoxia as: A. Low arterial oxygen levels B. Low tissue oxygenation C. Excess CO₂ retention D. Rapid breathing causing CO₂ loss

Answer – B. Low tissue oxygenation – Rationale: Hypoxia is inadequate oxygen delivery to tissues despite possible normal arterial oxygen levels.

The nurse identifies hypoventilation in a patient who: A. Retains carbon dioxide due to inadequate ventilation B. Rapidly eliminates carbon dioxide C. Has low tissue oxygenation D. Hyperventilates due to anxiety

Answer – A. Retains carbon dioxide due to inadequate ventilation – Rationale: Hypoventilation results in CO₂ buildup (hypercapnia) and decreased O₂ intake.

The nurse recognizes hyperventilation in a client with anxiety when: A. The patient exhibits slow, shallow respirations B. There is increased rate and depth of breathing leading to low CO₂ C. The oxygen saturation drops below 90% D. The respiratory rate is regular but shallow

Answer – B. There is increased rate and depth of breathing leading to low CO₂ – Rationale: Hyperventilation causes hypocapnia and symptoms like dizziness or tingling.

During percussion of the posterior chest, the nurse notes a dull sound over the left lower lobe. What does this finding indicate? A. Normal lung tissue B. Air trapping from COPD C. Fluid or consolidation in the lung D. Pneumothorax

Answer – C. Fluid or consolidation in the lung – Rationale: A dull percussion note occurs when air-filled alveoli are replaced by fluid, pus, or tissue—seen in pneumonia, effusion, or atelectasis.

The nurse performs tactile fremitus and notes stronger vibration over the right upper lobe compared with other areas. Which condition is most consistent with this finding? A. Pleural effusion B. Pneumothorax C. Lung consolidation such as pneumonia D. COPD

Answer – C. Lung consolidation such as pneumonia – Rationale: Increased tactile fremitus indicates denser lung tissue, which transmits vibrations more effectively, as seen in pneumonia.

The nurse observes bluish discoloration of the lips and tongue in a patient with COPD. How should this finding be documented? A. Peripheral cyanosis B. Central cyanosis C. Dependent cyanosis D. Acrocyanosis

Answer – B. Central cyanosis – Rationale: Central cyanosis (mucous membranes, lips, tongue) reflects decreased arterial oxygenation and is a sign of severe hypoxia requiring immediate intervention.

A client’s pulse oximetry reading is 88% on room air. What is the nurse’s priority action? A. Reposition the sensor and reassess B. Increase oxygen to 6 L/min immediately C. Document as baseline D. Encourage the client to drink fluids

Answer – A. Reposition the sensor and reassess – Rationale: Always verify accuracy first (check sensor placement, perfusion, nail polish). Persistent SpO₂ < 90% indicates hypoxemia and requires oxygen therapy per protocol.

Before a chest MRI, which nursing action is most important? A. Remove all metallic objects and screen for implanted devices B. Administer pre-procedure antibiotics C. Verify the patient is NPO 8 hours before test D. Obtain sputum specimen

Answer – A. Remove all metallic objects and screen for implanted devices – Rationale: MRI uses strong magnetic fields