Chapter 24: Assessment of the Respiratory System Ignatavicius:
Med- ical-Surgical Nursing, 10th Edition
1. 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
progno- sis: 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.
2. 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.
1/
, Chapter 24: Assessment of the Respiratory System Ignatavicius:
Med- ical-Surgical Nursing, 10th Edition
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.
3. 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.: 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.
4. 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
2/
Med- ical-Surgical Nursing, 10th Edition
1. 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
progno- sis: 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.
2. 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.
1/
, Chapter 24: Assessment of the Respiratory System Ignatavicius:
Med- ical-Surgical Nursing, 10th Edition
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.
3. 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.: 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.
4. 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
2/
