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Chapter 24: Assessment of the
Respiratory System Ignatavicius:
Medical-Surgical Nursing, 10th Edition
by Sharon lewis questions and detailed
answers 2025
100% A+ ACCURATE
- 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
ANS: C
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.
- 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.
ANS: C
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.
- 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.
ANS: D
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.
- 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?"
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. The nurse would ensure signed informed consent has been obtained. Verifying that the client understands complications and explaining the procedure to be performed will be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis
- 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.
ANS: D
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
- 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.
ANS: C
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
- 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
ANS: A
A client with dyspnea and the inability to complete activities such as climbing a flight of stairs without pausing has class IV dyspnea. The nurse would provide assistance with activities of daily living. These clients would be encouraged to participate in activities as tolerated. They would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.
- 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."
ANS: C
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
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
ANS: A, D
Varenicline has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse would assess for changes in behavior and thought processes, including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and orange-colored urine are not adverse effects of this medication. Decreased cravings are a therapeutic response to this medication.
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?"
ANS: A, B, D, E
Nurses would assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse would also document the allergies in a prominent place in the client's medical record. Asking about the last time the client ate avocados does not provide any pertinent information for
the client's plan of care. Asking how a client manages to avoid environmental allergies in this fashion also does not provide any pertinent information.
- 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."
ANS: A, D, E
To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours (depending on the suspected cause), 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 or the respiratory lab. A treadmill is not used for this test.
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."
ANS: A, D, E, F
Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset "nagging" cough, and pain that is worse at the end of inhalation and the end of exhalation on the affected side. Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of infection.
- 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
ANS: B, C, D, F
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
