Chapter 27: Assessment of the Respiratory System

1. 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 a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years

ANS: 45 pack-years 66 (current age) - 16 (year started smoking) = 50 years of smoking. (40 years ´ 1 pack per day) + (10 years ´ 0.5 pack per day) = 45 pack-years.

5. A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.)

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

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 client's morning bronchodilator medication." 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."

3. While obtaining a client's 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?" 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?"

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 client's plan of care

a. Assistance with activities of daily living

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

a. Document the findings.

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 client's plan of care? (Select all that apply.)

a. Encourage deep breathing and coughing. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins.

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 e. Increased thirst

6. 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?

b. "Do you have any chronic breathing problems?"

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

b. Absent breath sounds

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 client's level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

b. Assess the client's level of consciousness.

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?

b. Notify the Rapid Response Team.

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

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

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?

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

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

c. Client has reduced breath sounds. - Nurse calls physician immediately.

1. 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?

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

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

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

3. A nurse assesses 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

d. Occupation and hobbies

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

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

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

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