Deck 29: Assessment of the Respiratory System

Question 1

The nurse is caring for a client after a thoracentesis.Which assessment finding by the nurse warrants immediate action?

A) Client rates pain as 5/10 at the site of the procedure.
B) Small amount of drainage is noted from the site.
C) Pulse oximetry is 93% on 2 liters of oxygen.
D) Trachea is deviated toward opposite side of the neck.

Answer 1

Trachea is deviated toward opposite side of the neck.

Question 2

The nurse is caring for several clients on a respiratory unit.Which client does the nurse see first?

A) Older adult with an SaO₂ of 96% on room air
B) Adult client with an SaO₂ of 94% on 2 L/min
C) Young adult with an arterial oxygen level of 85%
D) Young adult with an arterial oxygen level of 94%

Answer 2

Young adult with an arterial oxygen level of 85%

Question 3

A client is scheduled to undergo a thoracentesis.What is the nurse's priority intervention?

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) Verify that informed consent has been given by the client.

Answer 3

Verify that informed consent has been given by the client.

Question 4

A client had a flexible bronchoscopy 2 hours ago and has become mildly cyanotic despite the application of oxygen.When giving change-of-shift report,which question by the oncoming nurse elicits the most useful information?

A) "How long was the client sedated for the procedure?"
B) "Were the oximetry readings during the test normal?"
C) "Are you sure the client was NPO before the bronchoscopy?"
D) "What kind of topical anesthetic was used on the client?"

Question 5

A client has a long-standing history of chronic obstructive pulmonary disease (COPD).Which laboratory finding does the nurse correlate with this condition?

A) White blood cell count, 7500/mm³
B) Hemoglobin, 22 g/dL
C) Neutrophils, 6000/ mm³
D) Monocytes, 600/mm³

Question 6

A client with long-standing pulmonary problems is classified as having class III dyspnea.Based on this classification,what type of assistance does the nurse anticipate providing for ADLs?

A) Dyspnea is minimal and the client requires no additional assistance.
B) The client may require rest periods during performance of ADLs.
C) The client requires assistance for some but not all tasks.
D) Owing to severe dyspnea, this client cannot participate in any self-care.

Question 7

A client tells the nurse that he usually expectorates about 2 ounces of thin,clear,colorless sputum each day,mostly in the morning after getting out of bed.What is the nurse's initial action after gaining this information?

A) Ask the client to provide a morning sputum sample for laboratory analysis.
B) Obtain a specimen of the sputum in a sterile container for culture.
C) Monitor for an increase in sputum production or a change in color.
D) Notify the health care provider and prepare the client for possible bronchoscopy.

Question 8

A client has undergone a thoracentesis.Which assessment finding requires immediate action by the nurse?

A) Decreased level of consciousness
B) Tachycardia
C) Increased temperature
D) Slowed respiratory rate

Question 9

A client is scheduled for pulmonary function tests (PFTs)in the morning.The nurse calls the client to teach about the procedure.Which statement by the client indicates a need for further teaching?

A) "I should not smoke for at least 6 hours before the test."
B) "PFTs can determine whether my lung problem has gotten worse."
C) "I should use my inhaler anytime during the test if I need it."
D) "If I get really short of breath, I'll tell the technician."

Question 10

A postoperative client has an oxygen saturation of 96% but is pale and dyspneic and says,"I can't get enough air!" The client's lung sounds are clear.Which action by the nurse is most appropriate?

A) Call the physician and request a hemoglobin and hematocrit level.
B) Notify respiratory therapy and request a breathing treatment.
C) Encourage the client to cough and deep breathe 10 times each hour.
D) Take the client's temperature and give antipyretics if needed.

Question 11

The nursing assistant reports to the nurse that an African-American client's pulse oximetry reading is 93%.The client has no complaints.Which action by the nurse is most appropriate?

A) Replace the sensor probe of the oximeter.
B) Place the probe on another finger.
C) Assess other signs of respiratory adequacy.
D) Prepare to obtain arterial blood gases.

Question 12

The nurse is calculating a client's smoking history in pack-years.The client has recently been diagnosed with lung cancer.Which is the nurse's priority intervention during the interview?

A) Encourage the client 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.

Question 13

The nurse is caring for four clients who had arterial blood gases (ABGs).Which laboratory value warrants immediate intervention by the nurse?

A) HCO₃^- of 25 mEq/L
B) SpO₂ of 96%
C) pH of 7.38
D) PaCO₂ of 48 mm Hg

Question 14

The nurse observes that a client's anteroposterior (AP)chest diameter is the same as his lateral chest diameter.What is the nurse's most important question for the client in response to this finding?

A) No questions are needed regarding this normal finding.
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?"

Question 15

A client with a history of chronic obstructive pulmonary disease (COPD)presents to the clinic with increased cough and low-grade temperature.Which question by the nurse elicits the most useful information?

A) "How long have you been sick?"
B) "Has your sputum changed color?"
C) "Is anyone else in your house sick?"
D) "Do you take any medications?"

Question 16

A client had a bronchoscopy 2 hours ago and is requesting water to drink.Which action by the nurse is most appropriate?

A) Call the physician and request an order for food and water.
B) Give the client ice chips instead of a drink of water.
C) Assess the client's gag reflex before giving anything.
D) Let the client have a small sip to see whether he or she can swallow.

Question 17

The nurse is assessing a client's breath sounds.Which assessment finding has been correctly linked to the nurse's primary intervention?

A) Hollow sounds heard over trachea; increase oxygen flow rate.
B) Crackles heard in bases; have the client cough forcefully.
C) Wheezes heard in central areas; administer inhaled bronchodilator.
D) Vesicular sounds heard over the periphery; have the client breathe deeply.

Question 18

The nurse is caring for an older adult client with a pulmonary infection.Which nursing action is a priority with this client?

A) Encouraging the client to increase fluid intake
B) Assessing the client's level of consciousness
C) Raising the head of the bed to at least 45 degrees
D) Providing the client with humidified oxygen

Question 19

When assessing a client's 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

Question 20

The nurse assesses a client after an open lung biopsy.Which assessment finding is matched with the correct intervention?

A) Client feels "dizzy;" nurse applies oxygen and pulse oximeter.
B) Client's heart rate is 55 beats/min; nurse withholds pain medication.
C) Client has reduced breath sounds; nurse calls physician immediately.
D) Client's respiratory rate is 18 breaths/min; nurse decreases oxygen flow rate.