Ch. 25 Assessment of Respiratory System - TB

A nurse observes that a client's 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?

"Do you have any chronic breathing problems?"

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 nurse collaborates with a respiratory therapist to complete pulmonary functions 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 medications." -"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 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."

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 reactions?"

A nurse plans care for a client who is at high risk for a pulmonary infection. Which 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 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.

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

Absent breath sounds.

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 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.

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 ADL's

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

Document the findings.

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 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 of highest priority for the nurse to obtain?

Occupation and hobbies

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

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

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

Visual hallucinations, impaired judgment