lOMoARcPSD|3013804
Chapter 24 notes
Care Management (Keiser
University)
, lOMoARcPSD|3013804
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 24: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 10th 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 60–pack-year smoking history. Which action is most important
for the nurse to take when interviewing this client?
a.
Tell the client that he or she 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.
ANS: C
Smoking assessments and cessation information can be an uncomfortable and sensitive topic
among both clients and health care providers. The nurse would maintain a nonjudgmental
attitude in order to foster trust with the client. Telling the client he or she needs to quit
smoking is paternalistic and threatening. Assessing exposure to smoke includes more than
tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a
history, it is most important to get accurate information.
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment MSC: Client Needs Category: Psychosocial Integrity
GRADESLAB.COM
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
the correct intervention?
a.
Client reports being dizzy—nurse calls the Rapid Response Team.
b.
Client’s heart rate is 55 beats/min—nurse withholds pain medication.
c.
Client has reduced breath sounds—nurse calls primary health care provider
immediately.
d.
Client’s 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 primary health care provider needs to be notified
immediately. Dizziness without other data would not lead the nurse to call the RRT. If the
client’s 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.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse assesses a client’s respiratory status. Which information is most important for the
nurse to obtain?
a.
Average daily fluid intake.
b.
Neck circumference.
Chapter 24 notes
Care Management (Keiser
University)
, lOMoARcPSD|3013804
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 24: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 10th 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 60–pack-year smoking history. Which action is most important
for the nurse to take when interviewing this client?
a.
Tell the client that he or she 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.
ANS: C
Smoking assessments and cessation information can be an uncomfortable and sensitive topic
among both clients and health care providers. The nurse would maintain a nonjudgmental
attitude in order to foster trust with the client. Telling the client he or she needs to quit
smoking is paternalistic and threatening. Assessing exposure to smoke includes more than
tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a
history, it is most important to get accurate information.
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment MSC: Client Needs Category: Psychosocial Integrity
GRADESLAB.COM
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
the correct intervention?
a.
Client reports being dizzy—nurse calls the Rapid Response Team.
b.
Client’s heart rate is 55 beats/min—nurse withholds pain medication.
c.
Client has reduced breath sounds—nurse calls primary health care provider
immediately.
d.
Client’s 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 primary health care provider needs to be notified
immediately. Dizziness without other data would not lead the nurse to call the RRT. If the
client’s 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.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse assesses a client’s respiratory status. Which information is most important for the
nurse to obtain?
a.
Average daily fluid intake.
b.
Neck circumference.
