Chapter 27: Assessment of the Respiratory System

Chapter 27: Assessment of the Respiratory System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

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?
   1. Tell the client that he needs to quit smoking to stop further cancer development.
   2. Encourage the client to be completely honest about both tobacco and marijuana

use.

1. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
2. 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/Application                         REF: 494

KEY:   Patient-centered care| smoking cessation

MSC:   Integrated Process: Communication and Documentation

NOT:   Client Needs Category: Psychosocial Integrity

2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
   1. Client states he is dizzy. – Nurse applies oxygen and pulse oximetry.
   2. Client’s heart rate is 55 beats/min. – Nurse withholds pain medication.
   3. Client has reduced breath sounds. – Nurse calls physician immediately.
   4. 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 physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. 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/Application                         REF: 512

KEY:   Assessment/diagnostic examination| respiratory distress/failure

MSC:   Integrated Process: Nursing Process: Implementation

NOT:          Client Needs Category: Physiological Integrity: Physiological Adaption

3. A nurse assesses a client’s respiratory status. Which information is of highest priority for the nurse to obtain?
   1. Average daily fluid intake
   2. Neck circumference
   3. Height and weight
   4. Occupation and hobbies

ANS:           D

Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client’s occupation and hobbies. Although it will be important for the nurse to assess the client’s fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client’s neck circumference will not be an important part of a respiratory assessment.

DIF:            Applying/Application                         REF: 496                     KEY: Assessment/diagnostic examination                                                                        MSC:             Integrated Process: Nursing Process: Assessment                                               NOT: Client Needs Category: Health Promotion and Maintenance

4. A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?
   1. Encourage the client to increase fluid intake.
   2. Assess the client’s level of consciousness.
   3. Raise the head of the bed to at least 45 degrees.
   4. Provide the client with humidified oxygen.

ANS:           B

Assessing the client’s 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/Application                         REF: 501

KEY:          Older adult| pulmonary infection

MSC:          Integrated Process: Nursing Process: Assessment                 NOT: Client Needs Category: Health Promotion and Maintenance

5. A nurse is providing care after auscultating clients’ breath sounds. Which assessment finding is correctly matched to the nurse’s primary intervention?
   1. Hollow sounds are heard over the trachea. – The nurse increases the oxygen flow rate.
   2. Crackles are heard in bases. – The nurse encourages the client to cough forcefully.
   3. Wheezes are heard in central areas. – The nurse administers an inhaled bronchodilator.
   4. 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/Application                         REF: 506                     KEY: Assessment/diagnostic examination                                                                        MSC:             Integrated Process: Nursing Process: Analysis                                                    NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation