Assessment of the Respiratory System

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?

Validate that informed consent has been given by the client

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

Verify that informed consent has been given by the client

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

Client has reduced breath sounds.- Nurse calls physician immediately

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the the lateral chest diameter. Which questions should the nurse ask the client in response to this finding?

"Do you have any chronic breathing problems?"

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?

"Do you have any chronic breathing problems?"

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching?

"Find an activity that you enjoy and will keep your hands busy." "Drink at least eight glasses of water each day." "Make a list of reasons you want to stop smoking."

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?

"Has your sputum changed color?"

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests?

"I held the client's morning bronchodilator medication." "I advised the client not to smoke for 6 hours prior to the test." " The client is alert and can follow your commands."

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?

"I should use my inhaler anytime during the test if I need it."

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

Client has reduced breath sounds; nurse calls physician immediately

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?

"Smoking while taking this medication will increase your risk of a stroke."

A client has 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?

"What kind of topical anesthetic was used on the client?"

While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best?

"What response do you have when you eat avocados?" "I will document this in your record so all of your providers will know." "Have you ever been treated for this allergic reaction?"

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?

Call the physician and request a hemoglobin and hematocrit level

A nurse assesses a 66-year -old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to half a pack per day." How many pack-years should the nurse document for this client?

45 pack-years

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care?

Assistance with activities of daily living

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

Absent breath sounds

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

Assess other signs of respiratory adequacy

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?

Assess the client's gag reflex before giving any food or water

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

Assess the client's gag-reflex before giving anything

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?

Assess the client's level of consciousness

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

Assessing the client's level of consciousness

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?

Document the findings

A nurse plans for a client who is at high risk for pulmonary infection. What interventions should the nurse include in this client's plan of care?

Encourage deep breathing and coughing AMbulate the client three times each day Provide a diet high in protein and vitamins

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

Hemoglobin, 22 g/dL

A nurse obtains the heath 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?

Maintain a non judgemental attitude to avoid causing the client to feel guilty

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?

Maintain a non judgemental attitude to avoid causing the client to feel guilty

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?

Monitor for an increase in sputum production or a change in color

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

Notify the Rapid Response Team

A nurse assesses a client's respiratory status. Which information is the highest priority for the nurse to obtain?

Occupation and hobbies

When assessing a client's respiratory status, which information is the highest priority for the nurse to obtain?

Occupation and hobbies

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

PaCO2 of 49 mm Hg

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

Tachycardia

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?

The client may require rest periods during performance of ADLs

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea deviated toward the opposite side of the neck

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

Trachea is deviated toward opposite side of the neck

A nurse assesses a client who is prescribed varenicline (Chantix for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication?

Visual hallucinations Impaired judgement

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?

Wheezes are heard in central areas.- The nurse administers an inhaled bronchodilator

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

Wheezes heard in central areas; administer inhaled bronchodilator

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

Young adult with an arterial oxygen of 85%