NCLEX Medical-Surgical: Respiratory Conditions 3 — Questions and Answers
Question 1: A nurse cares for a client with a chest tube. The water-seal chamber shows continuous bubbling. What does this indicate?
- An air leak in the system (Correct answer)
- Normal expected function
- Complete lung re-expansion
- Tube obstruction
Correct answer: An air leak in the system
Continuous bubbling in the water-seal chamber suggests an air leak that must be located and corrected.
Question 2: If a chest tube becomes disconnected from the drainage system, what is the priority action?
- Submerge the end of the tube in sterile water (Correct answer)
- Clamp the tube immediately and call the provider
- Reconnect quickly without cleaning
- Remove the tube from the client
Correct answer: Submerge the end of the tube in sterile water
Placing the tube end in sterile water re-establishes a water seal and prevents air from entering the pleural space.
Question 3: Which clinical sign suggests a tension pneumothorax?
- Tracheal deviation away from the affected side (Correct answer)
- Bilateral equal breath sounds
- Bradycardia and hypertension
- Productive cough
Correct answer: Tracheal deviation away from the affected side
Increasing intrathoracic pressure pushes mediastinal structures, deviating the trachea toward the unaffected side.
Question 4: A client develops sudden sharp chest pain and dyspnea after a deep-vein thrombosis. What is the nurse's first suspicion?
- Pulmonary embolism (Correct answer)
- Pneumonia
- Asthma attack
- Pleural effusion
Correct answer: Pulmonary embolism
A dislodged DVT clot traveling to the lung causes sudden pleuritic pain and dyspnea, classic for pulmonary embolism.
Question 5: Which position best promotes lung expansion in a client with respiratory distress?
- High-Fowler's position (Correct answer)
- Supine position
- Trendelenburg position
- Left lateral position
Correct answer: High-Fowler's position
High-Fowler's allows maximum diaphragm descent and chest expansion, easing the work of breathing.
Question 6: What should the nurse do when 'tidaling' (rising and falling with respiration) is seen in the water-seal chamber?
- Recognize it as expected normal function (Correct answer)
- Clamp the tube immediately
- Notify the provider of an emergency
- Increase wall suction
Correct answer: Recognize it as expected normal function
Tidaling reflects normal pressure changes in the pleural space with breathing and is expected.
Question 7: A client with a pulmonary embolism is started on heparin. Which lab value does the nurse monitor?
- Activated partial thromboplastin time (aPTT) (Correct answer)
- International normalized ratio (INR)
- Platelet aggregation only
- Serum potassium
Correct answer: Activated partial thromboplastin time (aPTT)
aPTT measures the therapeutic effect of heparin to guide dosing.
NCLEX Medical-Surgical: Respiratory Conditions 3
A nurse cares for a client with a chest tube.
The water-seal chamber shows continuous bubbling.
What does this indicate?