Ten free respiratory NCLEX practice questions with full rationales — asthma, COPD, chest tubes, pulmonary embolism, tuberculosis, pneumothorax, oxygen delivery devices, and airway suctioning. Answer each one, then reveal the correct answer and see why every option is right or wrong. No sign-up needed to practice here.
High-Yield Respiratory Review
Respiratory questions reward you for knowing which drugs and interventions are rescue versus maintenance. In an acute asthma exacerbation, the first move is a short-acting beta-2 agonist (SABA, such as albuterol) to open the airways; inhaled corticosteroids and leukotriene modifiers are daily controllers, not rescue therapy, and a long-acting beta-2 agonist (LABA) is never used as monotherapy in asthma. Teach peak-flow zones against the client's personal best: green (80-100%) means stay the course, yellow (50-80%) means use the rescue inhaler and follow the action plan, and red (below 50%) means emergency care. In COPD, oxygen is titrated to a target SpO2 of roughly 88-92%; never withhold needed oxygen, but avoid over-oxygenation that can worsen ventilation-perfusion mismatch and cause CO2 retention (hypercapnia). Reinforce pursed-lip breathing and tripod positioning, and choose a Venturi mask when a precise, controlled FiO2 is required.
Chest tubes generate constant test items. Expected findings are tidaling (fluctuation) in the water-seal chamber with respiration and gentle, CONTINUOUS bubbling in the suction-control chamber, which confirms the ordered suction is being applied. In the water-seal chamber, intermittent bubbling (on expiration, with coughing, or while air is still being evacuated) is also normal; only CONTINUOUS bubbling in the water-seal chamber signals an air leak. Loss of tidaling means the tube is obstructed/kinked or the lung has re-expanded. If the tube is pulled out of the CLIENT, apply an occlusive dressing taped on three sides (a flutter valve); if the system DISCONNECTS, submerge the tube's end in sterile water. Do not routinely clamp a chest tube. Recognize emergencies fast: pulmonary embolism presents with sudden dyspnea, pleuritic chest pain, tachycardia, and hypoxia (give oxygen, position upright, notify, anticipate anticoagulation), and a tension pneumothorax shows tracheal deviation AWAY from the affected side, absent breath sounds on that side, hypotension, and distended neck veins, requiring needle decompression.
Tuberculosis requires AIRBORNE precautions: a fit-tested N95 and a negative-pressure room. The RIPE regimen carries key teaching: isoniazid is hepatotoxic and depletes vitamin B6 (give pyridoxine); rifampin turns body fluids orange and reduces oral contraceptive effectiveness; pyrazinamide raises uric acid; and ethambutol can cause optic neuritis (report vision changes). Adherence, often via directly observed therapy (DOT), prevents resistance. For suctioning, hyperoxygenate before and after, apply suction only on withdrawal, limit each pass to 10-15 seconds, and do not routinely instill saline.
Respiratory NCLEX Practice Questions
Question 1 · Asthma
A client arrives at the emergency department with an acute asthma exacerbation, with audible wheezing, use of accessory muscles, and an SpO2 of 90% on room air. Which medication should the nurse anticipate administering first?
- A Nebulized albuterol, a short-acting beta-2 agonist
- B Oral montelukast, a leukotriene receptor antagonist
- C Inhaled fluticasone, an inhaled corticosteroid controller
- D Inhaled salmeterol, a long-acting beta-2 agonist
Show answer & rationale
Correct answer: A
During an acute exacerbation the priority is rapid bronchodilation, so nebulized albuterol, a short-acting beta-2 agonist (SABA), is the correct first drug. It relaxes bronchial smooth muscle within minutes, relieving wheezing and airflow obstruction. Inhaled fluticasone is a corticosteroid controller that reduces airway inflammation over days to weeks; it does nothing for the acute bronchospasm and is not a rescue agent. Salmeterol is a long-acting beta-2 agonist (LABA) with a slow onset used for maintenance only, and critically, a LABA is NEVER used as monotherapy in asthma because it increases the risk of severe exacerbations and death; it must be paired with an inhaled corticosteroid. Oral montelukast, a leukotriene receptor antagonist, is a controller for chronic management and allergic triggers, not for an acute attack. Clinical pearl: think 'rescue = short-acting, controller = daily.' A quick memory aid is 'A for Acute = Albuterol.' After the SABA, systemic corticosteroids are typically added to treat the underlying inflammation, and oxygen is given if SpO2 is below 92% and titrated to 92-95% (normal 95-100%). Reassess breath sounds, work of breathing, peak flow, and SpO2 after each treatment; worsening despite bronchodilators (a silent chest, rising CO2, or exhaustion) signals impending respiratory failure. Current guidelines (GINA) emphasize SABA plus early systemic steroids for moderate-to-severe exacerbations.
Question 2 · Asthma
During asthma teaching, a client whose personal-best peak expiratory flow is 400 L/min obtains a reading of 220 L/min. How should the nurse instruct the client to interpret and respond to this result?
- A Yellow zone: stop the daily inhaled corticosteroid until the reading normalizes
- B Green zone: continue the usual controller regimen and take no extra action
- C Yellow zone: use the quick-relief inhaler and follow the asthma action plan
- D Red zone: this is a medical emergency requiring immediate emergency care
Show answer & rationale
Correct answer: C
Peak-flow zones are calculated as a percentage of the client's personal best. Here 220/400 = 55%, which falls in the yellow zone (50-80%), a caution zone signaling worsening control. The correct action is to use the prescribed quick-relief (rescue) inhaler, such as albuterol, and follow the written asthma action plan, which may include stepping up therapy and rechecking the peak flow. The green-zone response is wrong because 55% is not 80-100%; the client is not at baseline and does need to intervene. The red-zone/emergency response is wrong because red is below 50% (here below 200 L/min) with severe symptoms; 55% warrants rescue medication and reassessment, not automatic emergency activation, though the client should seek care if it drops to red or does not improve. Stopping the inhaled corticosteroid is dangerous: controllers are continued (sometimes increased per the action plan), never discontinued during worsening control. Clinical pearl: 'Green go, Yellow caution, Red danger,' like a traffic light. Also reinforce good technique: shake the inhaler, use a spacer, exhale fully, actuate while beginning a slow deep breath, then hold the breath about 10 seconds; rinse the mouth after a corticosteroid inhaler to prevent thrush. Measuring peak flow at the same time daily and recording the personal best gives the reference for zone decisions.
Question 3 · COPD
A client with a COPD exacerbation has an SpO2 of 84% and increased work of breathing. Oxygen is started. Which action reflects safe oxygen management for this client?
- A Apply a non-rebreather mask at 15 L/min to achieve an SpO2 of 100%
- B Titrate oxygen to a target SpO2 of 88% to 92%
- C Set the nasal cannula at 6 L/min and leave it unchanged regardless of SpO2
- D Withhold oxygen entirely to avoid suppressing the hypoxic drive
Show answer & rationale
Correct answer: B
For most clients with COPD, oxygen is titrated to a target SpO2 of about 88-92%, which corrects dangerous hypoxemia while avoiding over-oxygenation. Withholding needed oxygen is never correct: hypoxemia at 84% is harmful, and the outdated fear of totally removing the 'hypoxic drive' does not justify letting a client stay dangerously low. However, driving the SpO2 to 100% with a high-flow non-rebreather is also wrong; over-oxygenation in COPD can worsen ventilation-perfusion matching and increase physiologic dead space, leading to CO2 retention (hypercapnia) and respiratory acidosis. A fixed high flow left unadjusted ignores the need to titrate to the target and to reassess; nasal cannula flow should be adjusted to reach 88-92%, and a Venturi mask is often preferred because it delivers a precise, controlled FiO2. Clinical pearl: 'In COPD, aim for 88-92, not a hundred and two.' Monitor for rising drowsiness, confusion, or a falling respiratory rate, which suggest CO2 narcosis, and obtain an ABG if the client deteriorates. Also reinforce pursed-lip breathing (prolongs exhalation, prevents air trapping) and tripod positioning to ease work of breathing. Signs of exacerbation to teach include increased dyspnea, change in sputum color or volume, and increased cough. Normal SpO2 in healthy adults is 95-100%, but chronic CO2 retainers are managed to a lower, individualized target.
Question 4 · Chest tube management
A nurse assesses a client whose chest tube is connected to a wet suction water-seal drainage system on postoperative day 2. Which findings are EXPECTED (normal)? Select all that apply.
- A Tidaling (fluctuation) in the water-seal chamber that rises and falls with respiration
- B Sudden cessation of tidaling one hour after insertion with worsening dyspnea
- C Gentle, continuous bubbling in the suction-control chamber
- D Approximately 50 mL of serosanguineous drainage collected over the shift
- E Continuous vigorous bubbling in the water-seal chamber
- F The drainage unit kept upright and positioned below the level of the chest
Show answer & rationale
Correct answer: A, C, D, F
Correct choices: Tidaling in the water-seal chamber — fluid rising on inspiration and falling on expiration (reversed with positive-pressure ventilation) — confirms system patency and reflects normal intrapleural pressure swings. In a WET suction system, gentle, CONTINUOUS bubbling in the suction-control chamber is the desired finding; it confirms the ordered suction level is actually being applied. Keeping the unit upright and below chest level uses gravity for drainage and prevents backflow into the pleural space. About 50 mL of serosanguineous drainage over a shift that is trending down is expected after thoracic surgery.
Why the others are wrong: Continuous vigorous bubbling in the WATER-SEAL chamber signals an air leak in the system or the client. Assess in order — check that all connections are tight and the tubing is intact first, then evaluate the client and the insertion site. Sudden cessation of tidaling shortly after insertion, especially with new dyspnea, suggests obstruction, a kink, or a dependent fluid-filled loop; correct the mechanical problem and reassess. (Late in recovery, loss of tidaling instead means the lung has fully re-expanded — context matters.)
Pearl: match the pattern to the chamber. INTERMITTENT bubbling in the water-seal chamber is NORMAL (air leaving the pleural space with exhalation/cough); only CONTINUOUS water-seal bubbling is abnormal. In the suction-control chamber, gentle CONTINUOUS bubbling is normal, while intermittent/absent bubbling means suction is too low. Report brisk output greater than ~100 mL/hr of fresh blood. Do not routinely clamp or strip the tube; current chest-drain guidance advises minimizing clamping. Keep an occlusive dressing, sterile water, and clamps at the bedside for emergencies.
Question 5 · Chest tube management
While repositioning a client, the nurse notes that the chest tube has been accidentally pulled out of the client's chest at the insertion site. What is the nurse's immediate action?
- A Submerge the exposed end of the tube in a bottle of sterile water
- B Reinsert the tube using sterile technique before calling the provider
- C Clamp the chest tube close to the insertion site
- D Cover the site with a sterile occlusive dressing taped on three sides
Show answer & rationale
Correct answer: D
When a chest tube is dislodged FROM THE CLIENT, immediately cover the insertion site with a sterile occlusive (petrolatum gauze) dressing taped on THREE sides. This creates a one-way flutter valve: air can escape during exhalation but cannot be pulled back in during inhalation, preventing a tension pneumothorax while you notify the provider. Taping all four sides would trap air and could cause a tension pneumothorax. Clamping the tube is wrong here because there is no tube in the chest to clamp, and clamping is avoided in general because it can convert a simple pneumothorax into a tension pneumothorax; chest tubes are not routinely clamped. Submerging the tube's end in sterile water is the action for a different problem, when the DRAINAGE SYSTEM DISCONNECTS from the tube (it re-establishes the water seal until a new unit is set up), not for a tube pulled out of the client. Reinserting the tube is outside nursing scope and risks injury; that is a provider procedure. Clinical pearl: 'Out of the CLIENT = occlusive dressing taped on three sides; DISCONNECTED from the system = submerge in sterile water.' Keep an occlusive dressing, a bottle of sterile water, and padded clamps at the bedside at all times. After stabilizing, assess breath sounds, respiratory effort, SpO2, and for tracheal deviation, and notify the provider for chest tube replacement and imaging.
Question 6 · Pulmonary embolism
A postoperative client suddenly develops dyspnea, pleuritic chest pain, tachycardia, restlessness, and an SpO2 of 86%. The nurse suspects a pulmonary embolism. Which nursing actions are appropriate? Select all that apply.
- A Encourage vigorous ambulation to help break up the clot
- B Administer supplemental oxygen
- C Raise the head of the bed to a high-Fowler position
- D Massage the calves to improve venous circulation
- E Notify the rapid response team or provider
- F Anticipate initiation of anticoagulation therapy
Show answer & rationale
Correct answer: B, C, E, F
A pulmonary embolism (PE) is a sudden emergency, and the classic presentation is abrupt dyspnea, pleuritic chest pain, tachycardia, anxiety/restlessness, and hypoxia. Correct actions all support oxygenation and rapid treatment. Administer supplemental oxygen to correct the hypoxemia (target at least 90-92%, normal SpO2 95-100%). Raise the head of the bed to high-Fowler to maximize lung expansion and ease the work of breathing. Notify the rapid response team or provider immediately, because PE can rapidly progress to hemodynamic collapse and needs urgent diagnostics (CT pulmonary angiography, D-dimer) and orders. Anticipate anticoagulation, typically starting heparin, which prevents new clot formation and lets the body lyse the existing clot; thrombolytics may be used for a massive PE with instability. The two incorrect actions are dangerous: vigorous ambulation and calf massage can dislodge additional deep-vein thrombus and shower more emboli to the lungs; the client should be kept on bed rest until stabilized. Clinical pearl: for sudden dyspnea plus chest pain plus hypoxia after surgery or immobility, 'think clot.' Prevention is central to NCLEX: early ambulation when appropriate, sequential compression devices, prophylactic anticoagulation, and adequate hydration reduce venous stasis. After starting heparin, monitor aPTT and for bleeding, and keep protamine sulfate available as the antidote.
Question 7 · Tuberculosis
A client is admitted with suspected active pulmonary tuberculosis and started on the RIPE regimen (rifampin, isoniazid, pyrazinamide, ethambutol). Which statement by the nurse is accurate?
- A Rifampin can turn body fluids orange and reduce oral contraceptive efficacy
- B Contact precautions with a surgical mask are sufficient for this client
- C Ethambutol commonly causes hepatotoxicity, so the client should avoid alcohol
- D Isoniazid causes optic neuritis, so the client should report any vision changes
Show answer & rationale
Correct answer: A
The accurate teaching is that rifampin turns body fluids (urine, sweat, tears) a harmless red-orange and induces liver enzymes that reduce the effectiveness of oral contraceptives, so clients need an additional or alternative birth-control method. The statement about contact precautions is wrong: TB spreads by the airborne route, requiring AIRBORNE precautions, a fit-tested N95 respirator (not a surgical mask) and a negative-pressure isolation room; the client wears a surgical mask only when transported. The remaining two statements swap the adverse effects. Hepatotoxicity is most associated with ISONIAZID (and also rifampin and pyrazinamide), so alcohol should be avoided and liver enzymes monitored; ethambutol's hallmark toxicity is OPTIC NEURITIS, causing decreased visual acuity and red-green color changes, so vision changes should be reported. Isoniazid also causes peripheral neuropathy by depleting vitamin B6, so pyridoxine (B6) is given prophylactically. Memory aids: 'Rifampin = Red-orange fluids'; 'Ethambutol = Eyes'; 'INH = I Need Hepatic (liver) checks + B6.' Emphasize strict adherence for 6-9 months, often through directly observed therapy (DOT), because inconsistent treatment breeds multidrug-resistant TB. The client can leave airborne isolation once clinically improving with three negative sputum acid-fast bacilli smears. Teach to report jaundice, dark urine, right-upper-quadrant pain, tingling, or vision changes promptly.
Question 8 · Oxygen delivery devices
A client with COPD requires an oxygen delivery device that provides a precise, controlled fraction of inspired oxygen (FiO2). Which device is most appropriate?
- A Simple face mask
- B Non-rebreather mask
- C Venturi mask
- D Nasal cannula
Show answer & rationale
Correct answer: C
The Venturi mask is the most appropriate choice when a precise, controlled FiO2 is needed, which is exactly the goal in COPD, where over-oxygenation can worsen CO2 retention. It uses interchangeable color-coded adapters that entrain a fixed ratio of room air, delivering exact concentrations (commonly 24%, 28%, 31%, 35%, 40%). A nasal cannula (about 1-6 L/min, roughly 24-44% FiO2) is comfortable and good for low-flow, stable needs, but the delivered FiO2 varies with the client's breathing pattern, so it is not precise. A simple face mask (about 6-10 L/min, roughly 40-60%) also delivers a variable, higher concentration and can accumulate CO2 if flow is too low; it is not controlled. A non-rebreather mask (about 10-15 L/min, up to roughly 90-100%) is for emergency high-concentration delivery in severe hypoxia, such as trauma or carbon monoxide poisoning, and would risk over-oxygenating a COPD client. Clinical pearl: match the device to the need. 'Venturi = Ventilation you can control (precise FiO2), ideal for COPD.' Escalate low to high: nasal cannula for mild needs, simple mask for moderate, non-rebreather for emergent high FiO2, and Venturi when accuracy matters most. Always verify the flow rate matches the prescribed FiO2 adapter, keep tubing unkinked, and reassess SpO2 (COPD target about 88-92%; normal 95-100%).
Question 9 · Airway suctioning
A nurse is preparing to suction a client with a tracheostomy who has copious secretions. Which actions reflect correct technique? Select all that apply.
- A Apply continuous suction while advancing the catheter into the airway
- B Use sterile technique when handling the suction catheter
- C Limit each suction pass to 10 to 15 seconds
- D Hyperoxygenate the client before and after suctioning
- E Routinely instill 5 to 10 mL of normal saline before each pass to loosen secretions
- F Apply suction only while withdrawing the catheter
Show answer & rationale
Correct answer: B, C, D, F
Safe suctioning centers on protecting oxygenation and the airway mucosa. Hyperoxygenate before and after (usually 100% oxygen for about 30 seconds) because suctioning removes oxygen along with secretions and can cause hypoxia and dysrhythmias. Apply suction ONLY on withdrawal, not on insertion, to avoid stripping oxygen and traumatizing the airway on the way in. Limit each pass to 10-15 seconds and allow the client to recover with oxygen between passes to prevent hypoxemia and bradycardia. Maintain sterile technique for tracheal suctioning to reduce infection risk. The two incorrect actions can harm the client: applying suction while advancing the catheter traumatizes the mucosa and worsens hypoxia, and routine instillation of normal saline is no longer recommended because it does not effectively thin secretions and can push bacteria into the lower airway, reduce oxygen saturation, and trigger coughing/desaturation. Clinical pearl: 'Suction OUT, not IN; keep it under 15; hyperoxygenate around it.' Monitor SpO2, heart rate, and rhythm throughout; stop and reoxygenate if the client desaturates or becomes bradycardic. Use the lowest effective suction pressure (about 100-120 mmHg for adults) and insert the catheter only until resistance is met, then withdraw slightly before applying suction. Suction based on assessment (audible secretions, decreased SpO2, coarse crackles), not on a fixed schedule.
Question 10 · Pneumothorax
A client involved in a motor vehicle collision develops severe respiratory distress, absent breath sounds on the right side, tracheal deviation toward the left, hypotension, and distended neck veins. How should the nurse interpret these findings and respond?
- A Hemothorax; place the client supine and begin oral fluids to restore blood pressure
- B Pleural effusion; schedule an elective thoracentesis for the next available slot
- C Simple pneumothorax; obtain a routine chest x-ray and continue to monitor before intervening
- D Tension pneumothorax; prepare for emergent needle decompression followed by chest tube insertion
Show answer & rationale
Correct answer: D
These findings describe a tension pneumothorax, a life-threatening emergency. Air enters the pleural space and cannot escape, building pressure that collapses the lung and shifts mediastinal structures. The hallmark signs are absent breath sounds on the affected side, tracheal deviation AWAY from the affected side (here, toward the left, indicating a right-sided tension pneumothorax), and signs of obstructed venous return and shock, namely hypotension and distended neck veins (JVD), along with severe distress and often tachycardia. The correct response is immediate intervention: prepare for emergent needle decompression (large-bore needle, classically second intercostal space, midclavicular line, or fifth intercostal space, anterior axillary line per current trauma guidance), followed by chest tube placement. Waiting for a routine x-ray is fatal; tension pneumothorax is a clinical diagnosis that must be treated before imaging. It is not a simple pneumothorax, which does not cause tracheal shift or hemodynamic collapse. It is not a hemothorax, and placing the client supine with oral fluids would not relieve the trapped air or the pressure; oral fluids are inappropriate in an unstable trauma client. A pleural effusion is a slower fluid collection managed electively, not this acute picture. Clinical pearl: 'Trachea deviates AWAY from the tension side; treat with a needle before the film.' Watch any pneumothorax for signs of tensioning, hence the rule against routinely clamping a chest tube, which can trap air and precipitate this emergency.
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Respiratory NCLEX FAQ
What is the difference between a rescue inhaler and a controller inhaler in asthma?
A rescue (quick-relief) inhaler is a short-acting beta-2 agonist like albuterol that rapidly relaxes airway muscle during an attack. Controllers, such as inhaled corticosteroids, are taken daily to reduce inflammation and prevent attacks; they do not relieve acute symptoms. Remember that a long-acting beta-2 agonist (LABA) is never used alone in asthma and must be combined with an inhaled corticosteroid. (Note: this SABA-as-rescue framing remains standard NCLEX teaching, though the newest GINA guidance now favors an as-needed ICS-formoterol reliever over SABA alone.)
Why is oxygen targeted to 88-92% in COPD instead of higher?
Clients with COPD who chronically retain CO2 can develop worsening hypercapnia if given too much oxygen. The main reason is not a loss of respiratory drive (these clients usually have a strong drive during exacerbations); rather, high oxygen reverses the lungs' protective hypoxic vasoconstriction, sending blood to poorly ventilated areas and increasing V/Q mismatch and dead space, and it shifts CO2 off hemoglobin via the Haldane effect. Titrating to about 88-92% corrects dangerous hypoxemia while limiting CO2 retention. Never withhold oxygen a client truly needs; simply avoid pushing the SpO2 toward 100%. A Venturi mask is ideal because it delivers a precise, controlled FiO2.
What do I do if a chest tube comes out versus if the system disconnects?
If the tube is pulled out of the client, immediately apply a sterile occlusive dressing taped on three sides so trapped air can escape but not re-enter, then notify the provider. If the tube separates from the drainage system, submerge the tube's end in sterile water to restore the water seal. Do not routinely clamp a chest tube, because clamping can cause a tension pneumothorax.
Which precautions and medication teaching points are highest-yield for tuberculosis?
TB requires airborne precautions: a fit-tested N95 and a negative-pressure room. For the RIPE regimen (rifampin, isoniazid, pyrazinamide, ethambutol), key teaching is isoniazid hepatotoxicity plus peripheral neuropathy (give vitamin B6), rifampin turning body fluids orange and lowering oral contraceptive effectiveness, pyrazinamide hepatotoxicity and elevated uric acid (gout/hyperuricemia risk), and ethambutol causing optic neuritis (report vision changes). Stress strict adherence, often via directly observed therapy, to prevent drug resistance.