TEST BANK ASSESMENT OF THE RESPIRATORY SYSTEM CHAPTER 27
Chapter 27: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nurse obtains the health history of a client who is recently diagnosed
with lung cancer and identifies that the client has a 60pack-year smoking
history. Which action is most important for the nurse to take when
interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer
development.
b. Encourage the client to be completely honest about both tobacco and
marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel
guilty.
d. Avoid giving the client false hope regarding cancer treatment and
prognosis.
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 beats/min. 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.
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/min is a normal
finding and would not warrant changing the oxygen flow rate.
,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
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.
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.
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.
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.
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.
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?
7. A nurse is assessing a client who is recovering from a lung biopsy.
Which assessment finding requires immediate action?
a. Increased temperature
b. Absent breath sounds
c. Productive cough
d. Incisional discomfort
, ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a
serious complication after a needle biopsy or open lung biopsy. The other
manifestations are not life threatening.
8. A nurse is caring for a client who is scheduled to undergo a
thoracentesis. Which intervention should the nurse complete prior to the
procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious
complications. Verifying that the client understands complications and
explaining the procedure to be performed will be done by the physician or
nurse practitioner, not the nurse. Measurement of oxygen saturation
before and after a 12-minute walk is not a procedure unique to a
thoracentesis.
9. A nurse assesses a client after a thoracentesis. Which assessment
finding warrants immediate action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 liters of oxygen.
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is
a medical emergency. The other findings are normal or near normal.
10. A nurse cares for a client who had a bronchoscopy 2 hours ago. The
client asks for a drink of water. Which action should the nurse take next?
a. Call the physician and request a prescription for food and water.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the clients gag reflex before giving any food or water.
Chapter 27: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nurse obtains the health history of a client who is recently diagnosed
with lung cancer and identifies that the client has a 60pack-year smoking
history. Which action is most important for the nurse to take when
interviewing this client?
a. Tell the client that he needs to quit smoking to stop further cancer
development.
b. Encourage the client to be completely honest about both tobacco and
marijuana use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel
guilty.
d. Avoid giving the client false hope regarding cancer treatment and
prognosis.
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 beats/min. 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.
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/min is a normal
finding and would not warrant changing the oxygen flow rate.
,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
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.
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.
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.
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.
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.
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?
7. A nurse is assessing a client who is recovering from a lung biopsy.
Which assessment finding requires immediate action?
a. Increased temperature
b. Absent breath sounds
c. Productive cough
d. Incisional discomfort
, ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a
serious complication after a needle biopsy or open lung biopsy. The other
manifestations are not life threatening.
8. A nurse is caring for a client who is scheduled to undergo a
thoracentesis. Which intervention should the nurse complete prior to the
procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious
complications. Verifying that the client understands complications and
explaining the procedure to be performed will be done by the physician or
nurse practitioner, not the nurse. Measurement of oxygen saturation
before and after a 12-minute walk is not a procedure unique to a
thoracentesis.
9. A nurse assesses a client after a thoracentesis. Which assessment
finding warrants immediate action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 liters of oxygen.
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is
a medical emergency. The other findings are normal or near normal.
10. A nurse cares for a client who had a bronchoscopy 2 hours ago. The
client asks for a drink of water. Which action should the nurse take next?
a. Call the physician and request a prescription for food and water.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the clients gag reflex before giving any food or water.
