NRNP6566 ADVANCED CARE OF ADULTS IN
ACUTE SETTINGS I WEEK 6 2026 SUCCESS
BLUEPRINT
◉ 2. A nurse assesses a client after an open lung biopsy. Which
assessment finding is matched with the correct intervention?
a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
b. Clients heart rate is 55 beatsmin. Nurse withholds pain
medication.
c. Client has reduced breath sounds. Nurse calls physician
immediately.
d. Clients respiratory rate is 18 breaths min. Nurse decreases oxygen
flow rate. Answer: ANS: C
A potentially serious complication after biopsy is pneumothorax,
which is indicated by decreased or absent breath sounds. The
physician needs to be notified immediately. Dizziness after the
procedure is not an expected finding. If the clients heart rate is 55
beats min, no reason is known to withhold pain medication. A
respiratory rate of 18 breaths
◉ 3. A nurse assesses a clients respiratory status. Which information
is of highest priority for the nurse to obtain? a. Average daily fluid
intake
b. Neck circumference
,c. Height and weight
d. Occupation and hobbies Answer: ANS: D
Many respiratory problems occur as a result of chronic exposure to
inhalation irritants used in a clients occupation and hobbies.
Although it will be important for the nurse to assess the clients fluid
intake, height, and weight, these will not be as important as
determining his occupation and hobbies. Determining the clients
neck circumference will not be an important part of a respiratory
assessment.
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 214
DIF: Applying
◉ 4. A nurse is caring for an older adult client who has a pulmonary
infection. Which action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the clients level of consciousness.
c. Raise the head of the bed to at least 45 degrees. d. Provide the
client with humidified oxygen. Answer: ANS: B
Assessing the clients level of consciousness will be most important
because it will show how the client is responding to the presence of
the infection. Although it will be important for the nurse to
encourage the client to turn, cough, and frequently breathe deeply;
raise the head of the bed; increase oral fluid intake; and humidify the
oxygen administered, none of these actions will be as important as
assessing the level of consciousness. Also, the client who has a
,pulmonary infection may not be able to cough effectively if an area
of abscess is present.
DIF: Applying
◉ 5. A nurse is providing care after auscultating clients breath
sounds. Which assessment finding is correctly matched to the nurses
primary intervention?
a. Hollow sounds are heard over the trachea. The nurse increases the
oxygen flow rate.
b. Crackles are heard in bases. The nurse encourages the client to
cough forcefully.
c. Wheezes are heard in central areas. The nurse administers an
inhaled bronchodilator. d. Vesicular sounds are heard over the
periphery. The nurse has the client breathe deeply. Answer: ANS: C
Wheezes are indicative of narrowed airways, and bronchodilators
help to open the air passages. Hollow sounds are typically heard
over the trachea, and no intervention is necessary. If crackles are
heard, the client may need a diuretic. Crackles represent a deep
interstitial process, and coughing forcefully will not help the client
expectorate secretions. Vesicular sounds heard in the periphery are
normal and require no intervention.
DIF: Applying
◉ 6. A nurse observes that a clients anteroposterior (AP) chest
diameter is the same as the lateral chest diameter. Which question
should the nurse ask the client in response to this finding?
, a. Are you taking any medications or herbal supplements?
b. Do you have any chronic breathing problems?
c. How often do you perform aerobic exercise?
d. What is your occupation and what are your hobbies? Answer:
ANS: B
The normal chest has a lateral diameter that is twice as large as the
AP diameter. When the AP diameter approaches or exceeds the
lateral diameter, the client is said to have a barrel chest. Most
commonly, barrel chest occurs as a result of a long-term chronic
airflow limitation problem, such as chronic obstructive pulmonary
disease or severe chronic asthma. It can also be seen in people who
have lived at a high altitude for many years. Therefore, an AP chest
diameter that is the same as the lateral chest diameter should be
rechecked but is not as indicative of underlying disease processes as
an AP diameter that exceeds the lateral diameter. Medications,
herbal supplements, and aerobic exercise are not associated with a
barrel chest. Although occupation and hobbies may expose a client
to irritants that can cause chronic lung disorders and barrel chest,
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 215
asking about chronic breathing problems is more direct and should
be asked first.
DIF: Applying
ACUTE SETTINGS I WEEK 6 2026 SUCCESS
BLUEPRINT
◉ 2. A nurse assesses a client after an open lung biopsy. Which
assessment finding is matched with the correct intervention?
a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
b. Clients heart rate is 55 beatsmin. Nurse withholds pain
medication.
c. Client has reduced breath sounds. Nurse calls physician
immediately.
d. Clients respiratory rate is 18 breaths min. Nurse decreases oxygen
flow rate. Answer: ANS: C
A potentially serious complication after biopsy is pneumothorax,
which is indicated by decreased or absent breath sounds. The
physician needs to be notified immediately. Dizziness after the
procedure is not an expected finding. If the clients heart rate is 55
beats min, no reason is known to withhold pain medication. A
respiratory rate of 18 breaths
◉ 3. A nurse assesses a clients respiratory status. Which information
is of highest priority for the nurse to obtain? a. Average daily fluid
intake
b. Neck circumference
,c. Height and weight
d. Occupation and hobbies Answer: ANS: D
Many respiratory problems occur as a result of chronic exposure to
inhalation irritants used in a clients occupation and hobbies.
Although it will be important for the nurse to assess the clients fluid
intake, height, and weight, these will not be as important as
determining his occupation and hobbies. Determining the clients
neck circumference will not be an important part of a respiratory
assessment.
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 214
DIF: Applying
◉ 4. A nurse is caring for an older adult client who has a pulmonary
infection. Which action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the clients level of consciousness.
c. Raise the head of the bed to at least 45 degrees. d. Provide the
client with humidified oxygen. Answer: ANS: B
Assessing the clients level of consciousness will be most important
because it will show how the client is responding to the presence of
the infection. Although it will be important for the nurse to
encourage the client to turn, cough, and frequently breathe deeply;
raise the head of the bed; increase oral fluid intake; and humidify the
oxygen administered, none of these actions will be as important as
assessing the level of consciousness. Also, the client who has a
,pulmonary infection may not be able to cough effectively if an area
of abscess is present.
DIF: Applying
◉ 5. A nurse is providing care after auscultating clients breath
sounds. Which assessment finding is correctly matched to the nurses
primary intervention?
a. Hollow sounds are heard over the trachea. The nurse increases the
oxygen flow rate.
b. Crackles are heard in bases. The nurse encourages the client to
cough forcefully.
c. Wheezes are heard in central areas. The nurse administers an
inhaled bronchodilator. d. Vesicular sounds are heard over the
periphery. The nurse has the client breathe deeply. Answer: ANS: C
Wheezes are indicative of narrowed airways, and bronchodilators
help to open the air passages. Hollow sounds are typically heard
over the trachea, and no intervention is necessary. If crackles are
heard, the client may need a diuretic. Crackles represent a deep
interstitial process, and coughing forcefully will not help the client
expectorate secretions. Vesicular sounds heard in the periphery are
normal and require no intervention.
DIF: Applying
◉ 6. A nurse observes that a clients anteroposterior (AP) chest
diameter is the same as the lateral chest diameter. Which question
should the nurse ask the client in response to this finding?
, a. Are you taking any medications or herbal supplements?
b. Do you have any chronic breathing problems?
c. How often do you perform aerobic exercise?
d. What is your occupation and what are your hobbies? Answer:
ANS: B
The normal chest has a lateral diameter that is twice as large as the
AP diameter. When the AP diameter approaches or exceeds the
lateral diameter, the client is said to have a barrel chest. Most
commonly, barrel chest occurs as a result of a long-term chronic
airflow limitation problem, such as chronic obstructive pulmonary
disease or severe chronic asthma. It can also be seen in people who
have lived at a high altitude for many years. Therefore, an AP chest
diameter that is the same as the lateral chest diameter should be
rechecked but is not as indicative of underlying disease processes as
an AP diameter that exceeds the lateral diameter. Medications,
herbal supplements, and aerobic exercise are not associated with a
barrel chest. Although occupation and hobbies may expose a client
to irritants that can cause chronic lung disorders and barrel chest,
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional
Collaborative Care 9e 215
asking about chronic breathing problems is more direct and should
be asked first.
DIF: Applying
