rxam 3

A nurse notices a patient leaning forward and using accessory muscles to breathe. What is the priority nursing action? 

 

• Place the patient in the orthopneic position.
• Provide supplemental oxygen without assessment.
• Encourage the patient to lie flat.
• Administer a bronchodilator immediately.

Answer explanation

Rationale: Sitting up and leaning forward allows maximum lung expansion and reduces the work of breathing in patients with respiratory distress. 

During a respiratory assessment, the nurse observes bluish lips and fingertips. What does this finding indicate? 

• Dehydration due to heat exposure.
• Cyanosis due to hypoxia.
• Allergic reaction to medication.
• Infection causing fever.

Answer explanation

Rationale: Cyanosis is caused by low oxygen levels in the blood and is a late sign of impaired gas exchange. 

The nurse hears high-pitched wheezing on auscultation in a patient with asthma. What does this indicate? 

• Airway narrowing from bronchospasm.
• Fluid accumulation in the lungs.
• Increased lung capacity due to hyperinflation.
• Normal airway function without obstruction.

Answer explanation

Rationale: Wheezing results from airflow through constricted bronchi and signals bronchospasm or obstruction. 

A COPD patient’s O₂ saturation is 95% on nasal cannula. What should the nurse do next? 

• Decrease the oxygen flow rate.
• Administer a bronchodilator immediately.
• Switch to a non-rebreather mask.
• Increase the oxygen flow rate.

Answer explanation

Rationale: COPD patients retain CO₂; too much oxygen suppresses their drive to breathe. Target SaO₂ is 88–92%. 

A nurse hears crackles at the lung bases in a patient with pneumonia. What is the most appropriate intervention? 

• Increase the patient's oxygen flow rate.
• Perform a chest X-ray right away.
• Administer antibiotics immediately.
• Encourage coughing, deep breathing, and ambulation.

Answer explanation

Rationale: Crackles indicate fluid in the alveoli. Mobilizing secretions improves ventilation and gas exchange. 

Which finding requires immediate provider notification in a patient recovering from tonsillectomy? 

• Severe throat pain.
• Low-grade fever.
• Nausea and vomiting.
• Frequent swallowing.

Answer explanation

Rationale: Excessive swallowing may indicate bleeding from the surgical site — a post-op emergency. 

A patient reports “a tickle in my throat” and hoarseness. What upper airway condition does the nurse suspect? 

• Laryngitis.
• Allergic Rhinitis
• Bronchitis
• Pharyngitis

Answer explanation

Rationale: Inflammation of the larynx causes hoarseness, dry cough, and loss of voice. 

A nurse caring for a patient with pulmonary edema observes pink frothy sputum. What is the first action? 

• Place the patient in a prone position.
• Sit the patient upright and administer oxygen.
• Administer diuretics immediately.
• Give the patient a sedative.

Answer explanation

Rationale: Pink frothy sputum indicates fluid in the lungs; positioning improves ventilation while oxygen supports oxygenation. 

Which sputum characteristic should alert the nurse to a possible bacterial infection? 

• Clear and thin sputum with no odor.
• Frothy white sputum with a sweet smell.
• Thick yellow or green sputum with foul odor.
• Rusty brown sputum with a metallic taste.

Answer explanation

Rationale: Purulent, discolored sputum indicates bacterial infection such as pneumonia or sinusitis. 

What is the correct use of an incentive spirometer after surgery? 

• Exhale quickly into the device.
• Hold your breath while using the device.
• Use the device only when feeling short of breath.
• Inhale slowly through the device.

Answer explanation

Rationale: The patient should breathe in, not blow out, to expand alveoli and prevent atelectasis.