NCLEX - RESPIRATORY Day 2 (Part 2)

The nurse caring for a client with emphysema provides teaching on pursed-lip breathing. Which statement by the client indicates effective learning?

• As my breathing improves, my lungs will begin to heal.
• Pursed-lip breathing will help my airways stay open.
• This is a relaxation technique to help with my anxiety.
• This will help reduce the fluid buildup in my lungs.
• –

Answer explanation

Pursed-lip breathing provides positive pressure to help prevent airway collapse during exhalation.

The nurse is caring for a 2-year-old with suspected epiglottitis. What action should the nurse take first?

• Directly examine the throat for exudate
• Check the client’s temperature using a rectal thermometer
• Place the client in the tripod position on the parent's lap
• Insert a peripheral venous access device for steroid administration
• –

Answer explanation

Tripod positioning helps improve airflow in a child with potential airway obstruction from epiglottitis.

The nurse teaches a client with chronic bronchitis who is fatigued and coughing up thick mucus. Which interventions should be included?

• Perform pursed-lips breathing several times daily.
• Sleep with a cool mist humidifier.
• Practice abdominal breathing and the huff cough technique.
• Drink at least 2 to 3 L of fluid daily.
• Take guaifenesin to reduce the viscosity of your respiratory secretions.

Answer explanation

These measures thin secretions and promote their clearance; pursed-lips breathing doesn’t reduce mucus thickness.

A client experiencing acute asthma exacerbation asks what medications they will receive. Which are appropriate?

• Albuterol
• Ibuprofen
• Ipratropium
• Tobramycin
• Montelukast

Answer explanation

Albuterol and ipratropium are immediate bronchodilators; others are inappropriate for acute episodes.

A community health nurse prepares a teaching plan for a client with latent TB prescribed isoniazid. Which instructions should be included?

• Avoid drinking alcohol
• Expect body fluids to change color to red
• Report yellowing of skin or sclera
• Report numbness and tingling of extremities
• Take with aluminum hydroxide to prevent gastric irritation

Answer explanation

Isoniazid can cause hepatotoxicity and peripheral neuropathy; alcohol worsens liver risk and symptoms must be reported.

The nurse reviews orders for a client with a severe COPD exacerbation. Which order should be clarified?

• IV morphine
• Albuterol via nebulizer
• IV methylprednisolone
• Oxygen via Venturi mask
• –

Answer explanation

Morphine may suppress respiratory drive in COPD clients—requires clarification before administration.

The nurse provides discharge instructions to a 67-year-old client with chronic bronchitis hospitalized for pneumonia. Which instructions should be included?

• Avoid OTC cough suppressants
• Oral antibiotics are not needed at home as IV was given
• Pneumonia vaccination is not needed as immunity is lifelong
• Schedule a follow-up with the HCP and chest x-ray
• Use a cool mist humidifier in your bedroom at night

Answer explanation

Cough suppressants can impair mucus clearance, and other measures support recovery and prevent recurrence.

A client with pneumonia was transferred to the ICU due to sepsis and respiratory failure. Which assessment finding is most important to report?

• Cough with mucus production
• Refractory hypoxemia
• Scattered rhonchi and crackles
• Temperature 101°F (38.3°C)
• –

Answer explanation

Refractory hypoxemia is the hallmark sign of ARDS—needs immediate medical intervention.

A client with COPD presses the call light saying "I can’t breathe." Vital signs are stable. What’s the most appropriate nursing intervention?

• Administer albuterol nebulizer
• Assist the client in identifying the trigger and ways to avoid it
• Coach the client through controlled breathing exercises
• Continue to monitor oxygen saturation
• –

Answer explanation

Controlled breathing calms anxiety and improves breathing in COPD when vitals are stable and no acute obstruction is present.