Chapter 22: Assessment of the Respiratory System

The nurse teaches a patient about pulmonary spirometry testing. Which statement by the patient indicates teaching was effective? "I should use my inhaler right before the test." "I won't eat or drink anything 8 hours before the test." "I will inhale deeply and blow out hard during the test." "My blood pressure and pulse will be checked every 15 minutes."

"I will inhale deeply and blow out hard during the test."

13. Which patient statement indicates that a patient admitted with acute asthma may need teaching regarding medication use? "I have not had any acute asthma attacks during the past year." "I became short of breath an hour before coming to the hospital." "I've been taking acetaminophen every 6 hours for chest wall pain." "I've used my albuterol inhaler frequently over the last 4 days."

"I've used my albuterol inhaler frequently over the last 4 days." The increased need for a rapid-acting bronchodilator would alert the patient that an acute attack may be imminent and that a change in therapy may be needed. albuterol inhaler is a short-acting bronchodilator used to relieve bronchospasm in conditions like asthma or chronic obstructive pulmonary disease (COPD)

10. The nurse is conducting a health history interview for a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). Which question is appropriate when assessing the patient's nutrition-metabolic pattern? 1) "Have you lost any weight recently?" 2) "Do you have trouble getting to the toilet?" 3) "Does your breathing wake you up in the night?" 4) "Do you have any pain associated with breathing?"

1) "Have you lost any weight recently?" When assessing the affect that COPD has on the patient's nutrition-metabolic pattern the appropriate question to ask is if the patient has experienced any weight loss.

15. The nurse is performing pulmonary function testing on a patient. Which nursing action is beneficial to the patient? 1) Assessing for respiratory distress 2) Scheduling the test after a meal 3) Providing rest before the procedure 4) Administering an inhaled bronchodilator six hours before procedure

1) Assessing for respiratory distress A nursing action that is appropriate when providing care to a patient who is having pulmonary function tests is to assess the patient for respiratory distress. The nurse would avoid 2, 3 , and 4

29. Which are age-related changes to the respiratory system's defense mechanisms? Select all that apply. 1) Decreased cilia function 2) Decreased chest wall compliance 3) Decreased response to hypoxemia 4) Decreased cell-mediated immunity 5) Decreased respiratory muscle strength

1) Decreased cilia function 4) Decreased cell-mediated immunity

1. The nurse educator is teaching a student nurse how to auscultate the lungs. Which action by the student nurse indicates the need for further education? 1) Listening to sound over the bony structures 2) Asking the client to sit in an upright position 3) Instructing the client to breathe slowly through mouth 4) Beginning auscultation from lung apices and moving toward intercostal spaces

1) Listening to sound over the bony structures Auscultation is performed to identify fluid, mucus, or obstruction in the respiratory system. The nurse should avoid auscultating sound over bony structures as it interferes with the sound quality. Breathing slowly through an open mouth prevents transmission of turbulent sound and helps to hear clear sound.

28. During the respiratory assessment, the nurse notes coarse crackles upon auscultation of the lung fields. Which diagnoses presents with this assessment finding? Select all that apply. 1) Pneumonia 2) Heart failure 3) Cystic fibrosis 4) Bronchospasm 5) Interstitial edema

1) Pneumonia 2) Heart failure Rhonchi is auscultated for patients diagnosed with cystic fibrosis. Wheezes are auscultated when the patient is experiencing bronchospasm. Discontinuous low pitched lung sounds are auscultated for patients experiencing interstitial edema.

20. The nurse is providing care to a patient who is diagnosed with asthma. Which noninvasive method will the nurse use to assess the patient's oxygenation status? 1) Pulse oximetry 2) Arterial blood gas 3) Venous blood gas 4) Cardiopulmonary monitor

1) Pulse oximetry

14. Which would the nurse assess when using palpation during the respiratory assessment? 1) Tracheal position 2) Bronchovesicular sounds 3) Lung density 4) Adventitious sounds

1) Tracheal position

27. Which questions are appropriate when assessing the effects of the patient's respiratory diagnosis on activity- exercise patterns? Select all that apply. 1) "Are you ever incontinent of urine when you cough?" 2) "Do you have trouble walking due to shortness of breath?" 3) "Does your spouse wake you in the middle of the night due to snoring?" 4) "How many flights of stairs can you walk before you are short of breath?" 5) "Do you ever feel full very quickly when eating due to your breathing issues?"

2) "Do you have trouble walking due to shortness of breath?" 4) "How many flights of stairs can you walk before you are short of breath?"

3. The nurse is conducting a respiratory assessment for a patient who is diagnosed with asthma. Which assessment finding indicates the patient is experiencing airway irritation?d 1) Hemoptysis 2) Dry, hacking cough 3) Harsh, barky cough 4) Loose-sounding cough

2) Dry, hacking cough A dry, hacking cough indicates the patient is experiencing airway irritation or obstruction. A harsh, barky cough suggests upper airway obstruction. A loose-sounding cough indicates secretions.

17. The nurse is caring for a patient with shortness of breath and respiratory rate of 28 breaths per minute. Which is the most preferred method to auscultate the chest of the patient with this condition? 1) Listening at the apices 2) Listening at the lung bases 3) Listening by comparing opposite areas of the chest 4) Listening to each cycle of inspiratory and expiratory cycle

2) Listening at the lung bases Listening at the lung bases is the most preferred method in a patient with respiratory distress. This is due to the increased respiratory rate and shortness of breath, which may tire the patient easily.

19. Which interconnected structure allows the movement of air between the alveoli? 1) Bronchioles 2) Pores of Kohn 3) Visceral pleura 4) Parietal pleura

2) Pores of Kohn

22. The nurse is providing care to a patient who is diagnosed with pneumonia. The patient admits to smoking one pack of cigarettes per day. Which respiratory defense mechanism may have failed to cause the patient's diagnosis? 1) Cough reflex 2) Filtration of air 3) Alveolar macrophages 4) Mucociliary clearance system

3) Alveolar macrophages Alveolar macrophages rapidly phagocytize inhaled foreign particles such as bacteria and often fail as a result of cigarette smoking.

8. The nurse is providing care to a patient who undergoes a sputum study. Which will the sputum study help to diagnose? 1) Asthma 2) Lung cancer 3) Bacterial lung infection 4) Chronic obstructive pulmonary disease

3) Bacterial lung infection A sputum study is often used to diagnose bacterial lung infections via a culture and sensitivity.

11. The nurse assesses a patient who presents with tachypnea and clubbing of the fingers. Based on this data, which diagnosis does the nurse anticipate for this patient? 1) Asthma 2) Chest trauma 3) Chronic hypoxemia 4) Chronic pulmonary obstructive disease

3) Chronic hypoxemia Pursed lip breathing, inability to lie in flat position, and use of accessory muscles to assist in breathing are findings observed in patients with asthma and chronic obstructive pulmonary disease. Voluntary decrease in tidal volume to reduce pain on chest expansion is referred as splinting, which is a common manifestation of chest trauma or pleurisy. Tachypnea and clubbing of the fingers are assessment findings that support the diagnosis of chronic hypoxemia.

16. The nurse is caring for a patient with a suspected pulmonary embolism. Which radiology study does the nurse anticipate to be beneficial for the patient? 1) Chest x-ray 2) Pulmonary angiogram 3) Computed tomography 4) Magnetic resonance imaging

3) Computed tomography Computed tomography (CT) is used in the diagnosis of lesions that are difficult to assess by conventional x-ray studies. Common types of CT are helical or spiral. Spiral CT is used to diagnose pulmonary embolism.

30. Which are age-related changes to respiratory control that may be observed when assessing the older adult patient? Select all that apply. 1) Less forceful cough 2) Calcification of costal cartilage 3) Decreased response to hypoxemia 4) Decrease in number of functional alveoli 5) Decreased response to hypercapnia

3) Decreased response to hypoxemia 5) Decreased response to hypercapnia

25. Which is the major muscle of respiration? 1) Accessory muscle 2) Intercostal muscle 3) Diaphragm muscle 4) Abdominal muscle

3) Diaphragm muscle

21. The nurse is conducting a respiratory assessment. Which respiratory manifestation indicates inadequate oxygenation? 1) Mild hypertension 2) Cool, clammy skin 3) Dyspnea on exertion 4) Unexplained apprehension

3) Dyspnea on exertion Dyspnea on exertion, or shortness of breath with activity, is a respiratory manifestation that indicates inadequate oxygenation.

4. The nurse is assessing a patient who is admitted with a persistent cough and is diagnosed with pulmonary edema. Which assessment finding supports the patient's diagnosis? 1) Foul smelling sputum 2) Clear, whitish, or yellow sputum 3) Large amounts of frothy, pink tinged sputum 4) Clear to gray with occasional specks of brown sputum

3) Large amounts of frothy, pink tinged sputum Large amounts of frothy pink-tinged sputumd support the diagnosis of pulmonary edema which is characterized by a persistent cough. Foul smelling sputum indicates an infection process. Clear, whitish, or yellow sputum is often found for patients diagnosed with chronic obstructive pulmonary disease especially in the early morning hours. Clear to grey sputum with brown specks indicates the patient is a smoker.

12. A patient is admitted to the emergency department (ED) with dyspnea. Upon assessment, the nurse notes a bluish discoloration of the patient's lips, fine crackles on auscultation, and dullness upon percussion of the lung fields. Based on this data, which diagnosis does the nurse anticipate? 1) Asthma 2) Pleural effusion 3) Pulmonary edema 4) Pulmonary fibrosis

3) Pulmonary edema Dyspnea, cyanosis, fine crackles and dullness on percussion all support the diagnosis of pulmonary edema. Tachypnea, diminished or absent breath sounds, and dullness on percussion support the diagnosis of pleural effusion. Tachypnea, crackles, and resonance on percussion support the diagnosis of pulmonary fibrosis.

2. The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement indicates appropriate understanding of the information presented? 1) "I will be awake and aware during the procedure." 2) "I will require mechanical ventilation after the procedure." 3) "I will need to have my prothrombin time drawn after the test." 4) "I will abstain from eating or drinking for eight hours prior to the procedure."

4) "I will abstain from eating or drinking for eight hours prior to the procedure." The patient will be sedated during the procedure. The patient will not require mechanical ventilation after this procedure. The patient will need to have the prothrombin time evaluated prior to the procedure, not after the procedure.

9. While auscultating a patient's chest, the nurse notes wheezing. Based on this data, which diagnosis does the nurse anticipate? 1) Bronchiectasis 2) Pleural effusion 3) Pulmonary edema 4) Chronic obstructive pulmonary disease

4) Chronic obstructive pulmonary disease Wheezes are continuous high-pitched squeaking or rapid sounds caused by the rapid vibration of the bronchial walls, which is caused by a blockage in airways which often due to conditions like asthma, chronic obstructive pulmonary disease (COPD), bronchitis, or allergic reactions.

23. What is the location of central chemoreceptors? 1) Lungs 2) Pores of Kohn 3) Roof of the nose 4) Medulla oblongata

4) Medulla oblongata

18. What is the function of the epiglottis? 1) To aid in the sensation of smell 2) To conduct gases to the alveoli 3) To filter small particles before air enters the lungs 4) To prevent the entry of solids and liquids into the lungs

4) To prevent the entry of solids and liquids into the lungs

17. After the nurse has received change-of-shift report, which patient would the nurse assess first? A patient with pneumonia who has crackles in the right lung base A patient with chronic bronchitis who has a low forced vital capacity A patient with possible lung cancer who has just returned after bronchoscopy A patient with hemoptysis and a 16-mm induration after tuberculin skin testing

A patient with possible lung cancer who has just returned after bronchoscopy Because thecough and gag are decreased after bronchoscopy, this patient would be assessed for airway patency

8. A patient with respiratory disease experiences a decrease in SpO2 from 93% to 87% while ambulating. Which action would be the nurse's priority? Notify the health care provider. Administer PRN supplemental O2. Document the response to exercise. Encourage the patient to pace activity.

Administer PRN supplemental O2. The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental O2 when exercising. the other actions are also important, but the first action would be to correct the hypoxemia.

13. Which is the term used to describe abnormal breath sounds? 1) Vesicular 2) Bronchial 3) Adventitious 4) Bronchovesicular

Adventitious Adventitious is the term used to describe abnormal breath sounds such as crackles, rhonchi, wheezes, and a pleural friction rub

14. A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT? Allergy to shellfish Apical pulse of 104 Respiratory rate of 30 O2 saturation of 90%

Allergy to shellfish Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media.

1. A patient is scheduled for a computed tomography (CT) scan of the chest with contrast media. Which assessment findings would the nurse report to the health care provider before the patient goes for theCT? (Select all that apply.) Allergy to shellfish Patient reports claustrophobia Elevated serum creatinine level Recent bronchodilator inhaler use Inability to remove a wedding band

Allergy to shellfish Elevated serum creatinine level Because the contrast media is iodine-based and may cause dehydration and decreased renal blood flow, asking about iodine allergies (such as allergy to shellfish) and monitoring renal function before the CT scan are necessary.

24. Which structure is located in the lower respiratory tract? 1) Alveoli 2) Larynx 3) Trachea 4) Pharynx

Alveoli

A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). Which action by thenurse will be most effective in improving the patient's adherence with discharge teaching? Have the patient repeat the instructions immediately after teaching. Accomplish the patient teaching just before the scheduled discharge. Arrange for the patient's caregiver to be present during the teaching. Start giving the patient discharge teaching during the admission process.

Arrange for the patient's caregiver to be present during the teaching.

5. The nurse palpates the posterior chest and notes absent fremitus while the patient says "toy boat". Which action would the nurse take next? Palpate the anterior chest and observe for barrel chest. Encourage the patient to turn, cough, and deep breathe. Review the chest x-ray report for evidence of pneumonia. Auscultate anterior and posterior breath sounds bilaterally.

Auscultate anterior and posterior breath sounds bilaterally. To assess for tactile fremitus, the nurse uses the palms of the hands to palpate for vibration while the patient repeats a word or phrase such as "toy boat." After noting absent fremitus, the nurse would then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis.

6. Which assessment finding for an older patient indicates that the nurse should take immediate action? Weak cough effort Barrel-shaped chest Dry mucous membranes Bilateral basilar crackles

Bilateral basilar crackles Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. the nurse should immediately accomplish further assessments, such as O2 saturation, and notify thehealth care provider.

1. A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of thepatient? Ask the patient to lie down for complete a full physical assessment. Complete the health history and check for allergies before treatment. Briefly ask specific questions about this episode of respiratory distress. Delay the physical assessment to first complete pulmonary function tests.

Briefly ask specific questions about this episode of respiratory distress. If respiratory distress is severe, only obtain pertinent information and defer a thorough assessment until thepatient's condition stabilizes. Obtaining a comprehensive health history or full physical examination is unnecessary until theacute distress has resolved. Brief questioning and a focused physical assessment should be done rapidly to help determine thecause of thedistress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete theentire admission database at this time. theinitial respiratory assessment must be completed before any diagnostic tests or interventions can be ordered.

7. The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. Which sounds would the nurse most likely hear on auscultation? Continuous rumbling, snoring, or rattling sounds mainly on expiration Continuous high-pitched musical sounds on inspiration and expiration Discontinuous high-pitched sounds of short duration during inspiration Discontinuous low-pitched sounds of long duration during inspiration

Discontinuous high-pitched sounds of short duration during inspiration Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration.

5. The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding supports this diagnosis? 1) Wheezing 2) Hemoptysis 3) Grey sputum 4) Slightly whitish sputum

Hemoptysis Tuberculosis is characterized by hemoptysis, which is the term for coughing up of blood or blood-tinged sputum from the respiratory tract. Wheezing is the term used to describe the asthma and emphysema.

22. While listening to the posterior chest of a patient who is experiencing acute shortness of breath, the nurse hears these sounds. How would the nurse document the lung sounds? Click here to listen to the audio clip Pleural friction rub Low-pitched crackles High-pitched wheezes Bronchial breath sounds

High-pitched wheezes Wheezes are continuous high-pitched or musical sounds heard initially with expiration.

4. On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third bilaterally. How should the nurse document this finding? Inspiratory crackles at the bases Expiratory wheezes in both lungs Abnormal lung sounds in the apices of both lungs Pleural friction rub in the right and left lower lobes

Inspiratory crackles at the bases Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during theexpiratory or inspiratory phase of therespiratory cycle.

6. A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which intervention will the nurse implement directly after the procedure? Encourage the patient to drink clear liquids. Place the patient on bed rest for at least 4 hours. Keep the patient NPO until the gag reflex returns. Maintain thehead of thebed elevated 90 degrees.

Keep the patient NPO until the gag reflex returns. Risk for aspiration and maintaining an open airway is thepriority. Because a local anesthetic is used to suppress thegag and cough reflexes during bronchoscopy, thenurse should monitor for thereturn of these reflexes before allowing thepatient to take oral fluids or food. the patient does not need to be on bed rest, and thehead of thebed does not need to be in thehigh-Fowler's position.

3. The arterial blood gas (ABG) results of a patient with diabetes show metabolic acidosis. Which compensatory finding would thenurse expect? Intercostal retractions Kussmaul respirations Low oxygen saturation (SpO2) Decreased venous O2 pressure

Kussmaul respirations Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis.

20. Which action could the nurse delegate to assistive personnel (AP)? Listen to a patient's lung sounds for wheezes or crackles. Label specimens obtained during percutaneous lung biopsy. Instruct a patient about how to use home spirometry testing. Measure induration at the site of a patient's intradermal skin test.

Label specimens obtained during percutaneous lung biopsy. Labeling of specimens at the bedside during a procedure is within thescope of practice of AP. the other actions require nursing judgment and should be done by licensed nursing personnel.

Which action by the nurse indicates a need to review respiratory assessment skills? Compares breath sounds from side to side at each level. Listens during the inspiratory phase, then moves the stethoscope. Starts at the apices of the lungs, moving down toward the lung bases. Instructs the patient to breathe slowly and deeply through the mouth.

Listens during the inspiratory phase, then moves the stethoscope. At each placement of the stethoscope, listen to at least one cycle of inspiration and expiration.

21. The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? O2 saturation is 88%. Blood pressure is 155/90 mm Hg. Respiratory rate is 24 breaths/min when lying flat. Pain level is 5 (on 0 to 10 scale) with a deep breath.

O2 saturation is 88%. O2 saturation should improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring.

19. Using the illustrated technique, the nurse is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)? Hyperresonance Tripod positioning Reduced excursion Accessory muscle use

Reduced excursion The technique for palpation for chest excursion is shown in the illustrated technique. Reduced chest movement would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion. Accessory muscle use and tripod positioning would be assessed by inspection.

6. When percussing the patient's lung fields, the nurse notes a moderately low-pitched sound over the chest. Which term does the nurse use to describe these sounds? 1) Dull 2) Tympany 3) Resonance 4) Hyperresonance

Resonance Low pitched sounds heard over normal lungs during percussion indicate resonance. Hyperresonance is a loud lower pitched sound heard when percussing hyperinflated lungs, which can occur in patients who are experiencing an acute asthma exacerbation

18. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted after increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider? Respirations are 36 breaths/min. Anterior-posterior chest ratio is 1:1. Lung expansion is decreased bilaterally. Hyperresonance to percussion is present.

Respirations are 36 breaths/min. The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as the administration of O2 or medications. The other findings are common chronic changes occurring in patients with COPD.

A patient admitted to the emergency department with a sudden onset of shortness of breath is diagnosed with a possible pulmonary embolus. How would the nurse prepare the patient for diagnostic testing to confirm the diagnosis? Ensure that the patient has been NPO. Review lab results to evaluate renal function. Inform radiology that radioactive glucose preparation is needed. Instruct the patient to expect to inspire deeply and exhale forcefully.

Review lab results to evaluate renal function. Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and the contrast media used may impair renal function, so patients with existing renal impairment would need special preparation and post-procedure care

2. The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient? High-Fowler's position with the left arm extended Supine with the head of the bed elevated 30 degrees On the right side with the left arm extended above the head Sitting upright with the arms supported on an over bed table

Sitting upright with the arms supported on an over bed table The upright position with thearms supported increases lung expansion, allows fluid to collect at thelung bases, and expands theintercostal space so that access to thepleural space is easier.

15. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding requires immediate action? The bicarbonate level (HCO3-) is 31 mEq/L. The arterial oxygen saturation (SaO2) is 92%. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.

The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg. pH: 7.35-7.45 PaCO₂ : 35-45 mm Hg PaO₂ : 75-100 mm Hg HCO₃: 22-26 mEq/L

7. Which diagnostic procedure is used to remove pleural fluid for analysis? 1) Lung biopsy 2) Bronchoscopy 3) Thoracentesis 4) Sputum studies

Thoracentesis A lung biopsy involves taking a sample of tissue, not fluid, for analysis. A bronchoscopy involves the use of a flexible fiberoptic scope for diagnosis, biopsy, or specimen collection. A thoracentesis is a diagnostic procedure used to remove pleural fluid for analysis or to instill medication. Sputum studies are obtained by expectoration and tracheal suction.

4. 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.) 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 consequence 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." f. "Set a quit date and stick to it."

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

3. 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.) a. "I held the client's 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."

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."

2. 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.) a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?" f. "How do manage to avoid grass and mold?"

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

9. 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? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 L per nasal cannula d. Complete bedrest with frequent repositioning

a. Assistance with activities of daily living A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without pausing has class IV dyspnea.

12. A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol.

a. Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse would document this finding.

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

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

1. 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.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine

a. Visual hallucinations d. Manic behavior

4. 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? 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?"

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

6. 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.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations

b. New-onset cough d. Tachypnea e. Pain with respirations Sudden sharp or stabbing chest pain Shortness of breath Rapid breathing Decreased breath sounds on the affected side

11. 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? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.

b. Notify the Rapid Response Team. Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify the Rapid Response Team to provide advanced care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat the client.

5. 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? a. Take a full set of vital signs. b. Obtain pulse oximetry reading. c. Ask the patient about hemoptysis. d. Inspect the biopsy site.

b. Obtain pulse oximetry reading. Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry reading and perform other respiratory assessments. Temperature is not a priority. The nurse can ask about other symptoms while conducting the assessment. The nurse would assess the biopsy site and/or dressings, but this is not the first action.

7. 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.) a. Provide a clear liquid breakfast. b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. e. Hold the client's bronchodilator. f. Monitor the client for at least 24 hours afterwards.

b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. f. Monitor the client for at least 24 hours afterwards. Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent aspiration, document allergies, and review laboratory results including complete blood count and bleeding times. There is no reason to hold the client's bronchodilator prior to this procedure. The nurse will monitor the client at least every 4 hours for 24 hours.

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

c. "Smoking while taking this medication will increase your risk of a stroke." Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping suddenly does not increase the risk of heart attack.

8. 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? a. Call the primary health care provider and request food and water for the client. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

c. Assess the client's gag reflex before giving any food or water. The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client's heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.

c. Client has reduced breath sounds—nurse calls primary health care provider immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The primary health care provider needs to be notified immediately. Dizziness without other data would not lead the nurse to call the RRT. If the client's 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 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he or she 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.

c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Smoking assessments and cessation information can be an uncomfortable and sensitive topic among both clients and health care providers. The nurse would maintain a nonjudgmental attitude in order to foster trust with the client. Telling the client he or she needs to quit smoking is paternalistic and threatening. Assessing exposure to smoke includes more than tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a history, it is most important to get accurate information.

3. A nurse assesses a client's respiratory status. Which information is most important 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. Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. This is part of the I-PREPARE assessment model for particulate matter exposure. Determining the client's neck circumference will not be an important part of a respiratory assessment.

7. 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 L of oxygen. d. The trachea is shifted toward the opposite side of the neck.

d. The trachea is shifted toward the opposite side of the neck. A shift of central thoracic structures toward one side is a sign of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal. The nurse would report this finding immediately or call the Rapid Response Team.

6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would 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.

d. Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would ensure signed informed consent has been obtained.