Chapter 24: Assessment of the Respiratory System

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 primary health care provider immediately.

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

Occupation and hobbies.

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask 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 would the nurse include in this client's teaching? (Select all that apply.)

"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." "Set a quit date and stick to it."

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

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

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

While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.)

"What happens when you are exposed to those things? "How do you treat these allergies?" "I will document this in your record so all so everyone knows." "Have you ever been in the hospital after an allergic response?"

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

Assistance with activities of daily living

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?

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

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

Document the findings.

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.)

Investigate all history of known exposures. Determine if breathing problems are worse at work. Ask the client what type of heating is in the home Gather details about the geographic location of the client's home Have client list all previous jobs and work experiences Assess what hobbies the client and family enjoy.

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?

Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.)

New-onset cough Tachypnea Pain with respirations

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. What action would the nurse take next?

Notify the Rapid Response Team.

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important?

Obtain pulse oximetry reading.

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

The trachea is shifted toward the opposite side of the neck.

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

Validate that informed consent has been given by the client.

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.)

Verify that the informed consent was obtained Document the client's allergies Review laboratory results. Monitor the client for at least 24 hours afterwards.

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.)

Visual hallucinations Manic behavior