Chapter 24: Assessment of the Respiratory
System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of
Risk Potential
2. 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.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Diagnostic testing MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
3. 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.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Respiratory assessment, Functional ability
MSC: Client Needs Category: Physiological Integrity: Basic Care and
Comfort
System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of
Risk Potential
2. 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.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Diagnostic testing MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
3. 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.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Respiratory assessment, Functional ability
MSC: Client Needs Category: Physiological Integrity: Basic Care and
Comfort
