adult health 2 test 1
Study online at https://quizlet.com/_8kut0m
1. 1. A nurse obtains the health history ANS: C
of a client who is recently diagnosed Smoking history includes the use of cigarettes,
with lung cancer and identifies that the cigars, pipe tobacco, marijuana, and other con-
client has a 60pack-year smoking his- trolled substances. Because the client may have
tory. Which action is most important guilt or denial about this habit, assume a non-
for the nurse to take when interview- judgmental attitude during the interview. This will
ing this client? encourage the client to be honest about the ex-
a. Tell the client that he needs to quit posure. Ask the client whether any of these sub-
smoking to stop further cancer devel- stances are used now or were used in the past.
opment. Assess whether the client has passive exposure
b. Encourage the client to be complete- to smoke in the home or workplace. If the client
ly honest about both tobacco and mar- smokes, ask for how long, how many packs per
ijuana use. c. Maintain a nonjudgmen- day, and whether he or she has quit smoking
tal attitude to avoid causing the client (and how long ago). Document the smoking his-
to feel guilty. tory in pack-years (number of packs smoked dai-
d. Avoid giving the client false hope ly multiplied by the number of years the client
regarding cancer treatment and prog- has smoked). Quitting smoking may not stop fur-
nosis. ther cancer development. This statement would
be giving the client false hope, which should be
avoided, but is not as important as maintaining a
nonjudgmental attitude.
DIF: Applying
2. 2. A nurse assesses a client after an ANS: C
open lung biopsy. Which assessment A potentially serious complication after biopsy is
finding is matched with the correct in- pneumothorax, which is indicated by decreased
tervention? or absent breath sounds. The physician needs to
a. Client states he is dizzy. Nurse ap- be notified immediately. Dizziness after the pro-
plies oxygen and pulse oximetry. cedure is not an expected finding. If the clients
b. Clients heart rate is 55 beatsmin. heart rate is 55 beats min, no reason is known to
Nurse withholds pain medication. withhold pain medication. A respiratory rate of 18
c. Client has reduced breath sounds. breaths
, adult health 2 test 1
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Nurse calls physician immediately.
d. Clients respiratory rate is 18 breaths
min. Nurse decreases oxygen flow
rate.
3. 3. A nurse assesses a clients respirato- ANS: D
ry status. Which information is of high- Many respiratory problems occur as a result of
est priority for the nurse to obtain? a. chronic exposure to inhalation irritants used in a
Average daily fluid intake clients occupation and hobbies. Although it will
b. Neck circumference be important for the nurse to assess the clients
c. Height and weight fluid intake, height, and weight, these will not be
d. Occupation and hobbies as important as determining his occupation and
hobbies. Determining the clients neck circumfer-
ence will not be an important part of a respiratory
assessment.
Test Bank - Medical-Surgical Nursing: Concepts
for Interprofessional Collaborative Care 9e 214
DIF: Applying
4. 4. A nurse is caring for an older adult ANS: B
client who has a pulmonary infection. Assessing the clients level of consciousness will
Which action should the nurse take be most important because it will show how the
first? client is responding to the presence of the infec-
a. Encourage the client to increase flu- tion. Although it will be important for the nurse
id intake. to encourage the client to turn, cough, and fre-
b. Assess the clients level of conscious- quently breathe deeply; raise the head of the bed;
ness. increase oral fluid intake; and humidify the oxy-
c. Raise the head of the bed to at least gen administered, none of these actions will be as
45 degrees. d. Provide the client with important as assessing the level of consciousness.
humidified oxygen. Also, the client who has a pulmonary infection
may not be able to cough effectively if an area of
, adult health 2 test 1
Study online at https://quizlet.com/_8kut0m
abscess is present.
DIF: Applying
5. 5. A nurse is providing care after ANS: C
auscultating clients breath sounds. Wheezes are indicative of narrowed airways, and
Which assessment finding is correctly bronchodilators help to open the air passages.
matched to the nurses primary inter- Hollow sounds are typically heard over the tra-
vention? chea, and no intervention is necessary. If crackles
a. Hollow sounds are heard over the are heard, the client may need a diuretic. Crackles
trachea. The nurse increases the oxy- represent a deep interstitial process, and cough-
gen flow rate. ing forcefully will not help the client expectorate
b. Crackles are heard in bases. The secretions. Vesicular sounds heard in the periph-
nurse encourages the client to cough ery are normal and require no intervention.
forcefully. DIF: Applying
c. Wheezes are heard in central ar-
eas. The nurse administers an inhaled
bronchodilator. d. Vesicular sounds are
heard over the periphery. The nurse
has the client breathe deeply.
6. 6. A nurse observes that a clients an- ANS: B
teroposterior (AP) chest diameter is The normal chest has a lateral diameter that is
the same as the lateral chest diameter. twice as large as the AP diameter. When the AP
Which question should the nurse ask diameter approaches or exceeds the lateral di-
the client in response to this finding? ameter, the client is said to have a barrel chest.
a. Are you taking any medications or Most commonly, barrel chest occurs as a result
herbal supplements? of a long-term chronic airflow limitation problem,
b. Do you have any chronic breathing such as chronic obstructive pulmonary disease
problems? or severe chronic asthma. It can also be seen
c. How often do you perform aerobic in people who have lived at a high altitude for
exercise? many years. Therefore, an AP chest diameter that
is the same as the lateral chest diameter should
, adult health 2 test 1
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d. What is your occupation and what be rechecked but is not as indicative of under-
are your hobbies? lying disease processes as an AP diameter that
exceeds the lateral diameter. Medications, herbal
supplements, and aerobic exercise are not associ-
ated with a barrel chest. Although occupation and
hobbies may expose a client to irritants that can
cause chronic lung disorders and barrel chest,
Test Bank - Medical-Surgical Nursing: Concepts
for Interprofessional Collaborative Care 9e 215
asking about chronic breathing problems is more
direct and should be asked first.
DIF: Applying
7. 7. A nurse is assessing a client who is ANS: B
recovering from a lung biopsy. Which Absent breath sounds may indicate that the client
assessment finding requires immedi- has a pneumothorax, a serious complication after
ate action? a needle biopsy or open lung biopsy. The other
a. Increased temperature manifestations are not life threatening.
b. Absent breath sounds DIF: Applying
c. Productive cough
d. Incisional discomfort
8. 8. A nurse is caring for a client who is ANS: D
scheduled to undergo a thoracentesis. A thoracentesis is an invasive procedure with
Which intervention should the nurse many potentially serious complications. Verifying
complete prior to the procedure? that the client understands complications and ex-
a. Measure oxygen saturation before plaining the procedure to be performed will be
and after a 12-minute walk. done by the physician or nurse practitioner, not
b. Verify that the client understands all the nurse. Measurement of oxygen saturation be-
possible complications. fore and after a 12-minute walk is not a procedure
c. Explain the procedure in detail to the
Study online at https://quizlet.com/_8kut0m
1. 1. A nurse obtains the health history ANS: C
of a client who is recently diagnosed Smoking history includes the use of cigarettes,
with lung cancer and identifies that the cigars, pipe tobacco, marijuana, and other con-
client has a 60pack-year smoking his- trolled substances. Because the client may have
tory. Which action is most important guilt or denial about this habit, assume a non-
for the nurse to take when interview- judgmental attitude during the interview. This will
ing this client? encourage the client to be honest about the ex-
a. Tell the client that he needs to quit posure. Ask the client whether any of these sub-
smoking to stop further cancer devel- stances are used now or were used in the past.
opment. Assess whether the client has passive exposure
b. Encourage the client to be complete- to smoke in the home or workplace. If the client
ly honest about both tobacco and mar- smokes, ask for how long, how many packs per
ijuana use. c. Maintain a nonjudgmen- day, and whether he or she has quit smoking
tal attitude to avoid causing the client (and how long ago). Document the smoking his-
to feel guilty. tory in pack-years (number of packs smoked dai-
d. Avoid giving the client false hope ly multiplied by the number of years the client
regarding cancer treatment and prog- has smoked). Quitting smoking may not stop fur-
nosis. ther cancer development. This statement would
be giving the client false hope, which should be
avoided, but is not as important as maintaining a
nonjudgmental attitude.
DIF: Applying
2. 2. A nurse assesses a client after an ANS: C
open lung biopsy. Which assessment A potentially serious complication after biopsy is
finding is matched with the correct in- pneumothorax, which is indicated by decreased
tervention? or absent breath sounds. The physician needs to
a. Client states he is dizzy. Nurse ap- be notified immediately. Dizziness after the pro-
plies oxygen and pulse oximetry. cedure is not an expected finding. If the clients
b. Clients heart rate is 55 beatsmin. heart rate is 55 beats min, no reason is known to
Nurse withholds pain medication. withhold pain medication. A respiratory rate of 18
c. Client has reduced breath sounds. breaths
, adult health 2 test 1
Study online at https://quizlet.com/_8kut0m
Nurse calls physician immediately.
d. Clients respiratory rate is 18 breaths
min. Nurse decreases oxygen flow
rate.
3. 3. A nurse assesses a clients respirato- ANS: D
ry status. Which information is of high- Many respiratory problems occur as a result of
est priority for the nurse to obtain? a. chronic exposure to inhalation irritants used in a
Average daily fluid intake clients occupation and hobbies. Although it will
b. Neck circumference be important for the nurse to assess the clients
c. Height and weight fluid intake, height, and weight, these will not be
d. Occupation and hobbies as important as determining his occupation and
hobbies. Determining the clients neck circumfer-
ence will not be an important part of a respiratory
assessment.
Test Bank - Medical-Surgical Nursing: Concepts
for Interprofessional Collaborative Care 9e 214
DIF: Applying
4. 4. A nurse is caring for an older adult ANS: B
client who has a pulmonary infection. Assessing the clients level of consciousness will
Which action should the nurse take be most important because it will show how the
first? client is responding to the presence of the infec-
a. Encourage the client to increase flu- tion. Although it will be important for the nurse
id intake. to encourage the client to turn, cough, and fre-
b. Assess the clients level of conscious- quently breathe deeply; raise the head of the bed;
ness. increase oral fluid intake; and humidify the oxy-
c. Raise the head of the bed to at least gen administered, none of these actions will be as
45 degrees. d. Provide the client with important as assessing the level of consciousness.
humidified oxygen. Also, the client who has a pulmonary infection
may not be able to cough effectively if an area of
, adult health 2 test 1
Study online at https://quizlet.com/_8kut0m
abscess is present.
DIF: Applying
5. 5. A nurse is providing care after ANS: C
auscultating clients breath sounds. Wheezes are indicative of narrowed airways, and
Which assessment finding is correctly bronchodilators help to open the air passages.
matched to the nurses primary inter- Hollow sounds are typically heard over the tra-
vention? chea, and no intervention is necessary. If crackles
a. Hollow sounds are heard over the are heard, the client may need a diuretic. Crackles
trachea. The nurse increases the oxy- represent a deep interstitial process, and cough-
gen flow rate. ing forcefully will not help the client expectorate
b. Crackles are heard in bases. The secretions. Vesicular sounds heard in the periph-
nurse encourages the client to cough ery are normal and require no intervention.
forcefully. DIF: Applying
c. Wheezes are heard in central ar-
eas. The nurse administers an inhaled
bronchodilator. d. Vesicular sounds are
heard over the periphery. The nurse
has the client breathe deeply.
6. 6. A nurse observes that a clients an- ANS: B
teroposterior (AP) chest diameter is The normal chest has a lateral diameter that is
the same as the lateral chest diameter. twice as large as the AP diameter. When the AP
Which question should the nurse ask diameter approaches or exceeds the lateral di-
the client in response to this finding? ameter, the client is said to have a barrel chest.
a. Are you taking any medications or Most commonly, barrel chest occurs as a result
herbal supplements? of a long-term chronic airflow limitation problem,
b. Do you have any chronic breathing such as chronic obstructive pulmonary disease
problems? or severe chronic asthma. It can also be seen
c. How often do you perform aerobic in people who have lived at a high altitude for
exercise? many years. Therefore, an AP chest diameter that
is the same as the lateral chest diameter should
, adult health 2 test 1
Study online at https://quizlet.com/_8kut0m
d. What is your occupation and what be rechecked but is not as indicative of under-
are your hobbies? lying disease processes as an AP diameter that
exceeds the lateral diameter. Medications, herbal
supplements, and aerobic exercise are not associ-
ated with a barrel chest. Although occupation and
hobbies may expose a client to irritants that can
cause chronic lung disorders and barrel chest,
Test Bank - Medical-Surgical Nursing: Concepts
for Interprofessional Collaborative Care 9e 215
asking about chronic breathing problems is more
direct and should be asked first.
DIF: Applying
7. 7. A nurse is assessing a client who is ANS: B
recovering from a lung biopsy. Which Absent breath sounds may indicate that the client
assessment finding requires immedi- has a pneumothorax, a serious complication after
ate action? a needle biopsy or open lung biopsy. The other
a. Increased temperature manifestations are not life threatening.
b. Absent breath sounds DIF: Applying
c. Productive cough
d. Incisional discomfort
8. 8. A nurse is caring for a client who is ANS: D
scheduled to undergo a thoracentesis. A thoracentesis is an invasive procedure with
Which intervention should the nurse many potentially serious complications. Verifying
complete prior to the procedure? that the client understands complications and ex-
a. Measure oxygen saturation before plaining the procedure to be performed will be
and after a 12-minute walk. done by the physician or nurse practitioner, not
b. Verify that the client understands all the nurse. Measurement of oxygen saturation be-
possible complications. fore and after a 12-minute walk is not a procedure
c. Explain the procedure in detail to the
