adult health 2 test 1
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.
ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled
substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental
attitude during the interview. This will encourage the client to be honest about the exposure. Ask the
client whether any of these substances are used now or were used in the past. Assess whether the client
has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how
many packs per day, and whether he or she has quit smoking (and how long ago). Document the
smoking history in pack-years (number of packs smoked daily multiplied by the number of years the
client has smoked). Quitting smoking may not stop further cancer development. This statement would
be giving the client false hope, which should be avoided, but is not as important as maintaining a
nonjudgmental attitude.
DIF: Applying
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.
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
,Brainpower
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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.
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.
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.
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?
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
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.
DIF: Applying
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?
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.
ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled
substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental
attitude during the interview. This will encourage the client to be honest about the exposure. Ask the
client whether any of these substances are used now or were used in the past. Assess whether the client
has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how
many packs per day, and whether he or she has quit smoking (and how long ago). Document the
smoking history in pack-years (number of packs smoked daily multiplied by the number of years the
client has smoked). Quitting smoking may not stop further cancer development. This statement would
be giving the client false hope, which should be avoided, but is not as important as maintaining a
nonjudgmental attitude.
DIF: Applying
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.
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
,Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:05
/
0:15
Full screen
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.
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.
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.
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?
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
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.
DIF: Applying
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?
