Chapter 24: Assessment of the Respiratory System

11. 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 clients plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

ANS: A A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

14. A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowlers position. d. Administer prescribed albuterol.

ANS: A Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the clients position because the finding is normal.

2. A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

ANS: A, C, D Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.

1. 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? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

ANS: A, D Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.

3. While obtaining a clients health history, the client states, I am allergic to avocados. Which responses by the nurse are best? (Select all that apply.) a. What response do you have when you eat avocados? b. I will remove any avocados that are on your lunch tray. c. When was the last time you ate foods containing avocados? d. I will document this in your record so all of your providers will know. e. Have you ever been treated for this allergic reaction?

ANS: A, D, E Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the clients medical record. The nurse should collaborate with food services to ensure no avocados are placed on the clients meal trays. Asking about the last time the client ate avocados does not provide any pertinent information for the clients plan of care.

5. A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Find an activity that you enjoy and will keep your hands busy. b. Keep snacks like potato chips on hand to nibble on. c. Identify a punishment for yourself in case you backslide. d. Drink at least eight glasses of water each day. e. Make a list of reasons you want to stop smoking.

ANS: A, D, E The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.

4. 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? (Select all that apply.) a. I held the clients morning bronchodilator medication. b. The client is ready to go down to radiology for this examination. c. Physical therapy states the client can run on a treadmill. d. I advised the client not to smoke for 6 hours prior to the test. e. The client is alert and can follow your commands.

ANS: A, D, E To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.

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.

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.

13. 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? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the clients peripheral pulses. d. Obtain blood and sputum cultures.

ANS: B Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the clients oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

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, asking about chronic breathing problems is more direct and should be asked first.

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 beats/min. 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/min is a normal finding and would not warrant changing the oxygen flow rate.

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.

12. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this clients teaching? a. Make a list of reasons why smoking is a bad habit. b. Rise slowly when getting out of bed in the morning. c. Smoking while taking this medication will increase your risk of a stroke. d. Stopping this medication suddenly increases your risk for a heart attack.

ANS: C Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate.

10. 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? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the clients gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

ANS: C The topical anesthetic used during the procedure will have affected the clients gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

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.

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? 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. Validate that informed consent has been given by the client.

ANS: D A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

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.

9. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck.

ANS: D A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.