TEST BANK FOR ADULT
x x x x
HEALTH NURSING REVIEWED
x x x
QUESTIONS AND ANSWERS x x x x
1. xA xnurse xobtains xthe xhealth xhistory xof xa xclient xwho xis xrecently xdiagnosed xwith xlung xcancer xand
xidentifies xthat xthe xclient xhas xa x60pack-year xsmoking xhistory. xWhich xaction xis xmost ximportant xfor
xthe xnurse xto xtake xwhen xinterviewing xthis xclient? x
a. Tell xthe xclient xthat xhe xneeds xto xquit xsmoking xto xstop xfurther xcancer xdevelopment. x
b. Encourage xthe xclient xto xbe xcompletely xhonest xabout xboth xtobacco xand xmarijuana xuse. xc.
xMaintain xa xnonjudgmental xattitude xto xavoid xcausing xthe xclient xto xfeel xguilty. x
d. xAvoid xgiving xthe xclient xfalse xhope xregarding xcancer xtreatment xand xprognosis. x- xCORRECT
xANSWER x-
ANS: xC x
Smoking xhistory xincludes xthe xuse xof xcigarettes, xcigars, xpipe xtobacco, xmarijuana, xand xother
xcontrolled xsubstances. xBecause xthe xclient xmay xhave xguilt xor xdenial xabout xthis xhabit, xassume xa
xnonjudgmental xattitude xduring xthe xinterview. xThis xwill xencourage xthe xclient xto xbe xhonest xabout xthe
xexposure. xAsk xthe xclient xwhether xany xof xthese xsubstances xare xused xnow xor xwere xused xin xthe xpast.
xAssess xwhether xthe xclient xhas xpassive xexposure xto xsmoke xin xthe xhome xor xworkplace. xIf xthe xclient
xsmokes, xask xfor xhow xlong, xhow xmany xpacks xper xday, xand xwhether xhe xor xshe xhas xquit xsmoking
x(and xhow xlong xago). xDocument xthe xsmoking xhistory xin xpack-years x(number xof xpacks xsmoked xdaily
xmultiplied xby xthe xnumber xof xyears xthe xclient xhas xsmoked). xQuitting xsmoking xmay xnot xstop xfurther
xcancer xdevelopment. xThis xstatement xwould xbe xgiving xthe xclient xfalse xhope, xwhich xshould xbe
xavoided, xbut xis xnot xas ximportant xas xmaintaining xa xnonjudgmental xattitude. x
DIF: xApplying x
x
2. xA xnurse xassesses xa xclient xafter xan xopen xlung xbiopsy. xWhich xassessment xfinding xis xmatched xwith
xthe xcorrect xintervention? x
a. Client xstates xhe xis xdizzy. xNurse xapplies xoxygen xand xpulse xoximetry. x
b. Clients xheart xrate xis x55 xbeatsmin. xNurse xwithholds xpain xmedication. x
c. Client xhas xreduced xbreath xsounds. xNurse xcalls xphysician ximmediately. x
d. Clients xrespiratory xrate xis x18 xbreaths xmin. xNurse xdecreases xoxygen xflow xrate. x- xCORRECT
xANSWER xANS: xC x
,A xpotentially xserious xcomplication xafter xbiopsy xis xpneumothorax, xwhich xis xindicated xby xdecreased xor
xabsent xbreath xsounds. xThe xphysician xneeds xto xbe xnotified ximmediately. xDizziness xafter xthe
xprocedure xis xnot xan xexpected xfinding. xIf xthe xclients xheart xrate xis x55 xbeats xmin, xno xreason xis
xknown xto xwithhold xpain xmedication. xA xrespiratory xrate xof x18 xbreaths x
x
3. xA xnurse xassesses xa xclients xrespiratory xstatus. xWhich xinformation xis xof xhighest xpriority xfor xthe
xnurse xto xobtain? xa. xAverage xdaily xfluid xintake x
b. Neck xcircumference x
c. Height xand xweight x
d. Occupation xand xhobbies x- xCORRECT xANSWER x-ANS: xD x
Many xrespiratory xproblems xoccur xas xa xresult xof xchronic xexposure xto xinhalation xirritants xused xin xa
xclients xoccupation xand xhobbies. xAlthough xit xwill xbe ximportant xfor xthe xnurse xto xassess xthe xclients
xfluid xintake, xheight, xand xweight, xthese xwill xnot xbe xas ximportant xas xdetermining xhis xoccupation xand
xhobbies. x
Determining xthe xclients xneck xcircumference xwill xnot xbe xan ximportant xpart xof xa xrespiratory
xassessment. x
Test xBank x- xMedical-Surgical xNursing: xConcepts xfor xInterprofessional xCollaborative xCare x9e x214
x x DIF: xApplying x
x
4. xA xnurse xis xcaring xfor xan xolder xadult xclient xwho xhas xa xpulmonary xinfection. xWhich xaction xshould
xthe xnurse xtake xfirst? x
a. Encourage xthe xclient xto xincrease xfluid xintake. x
b. Assess xthe xclients xlevel xof xconsciousness. x
c. Raise xthe xhead xof xthe xbed xto xat xleast x45 xdegrees. xd. xProvide xthe xclient xwith xhumidified xoxygen.
x- x
CORRECT xANSWER x-ANS: xB x
Assessing xthe xclients xlevel xof xconsciousness xwill xbe xmost ximportant xbecause xit xwill xshow xhow xthe
xclient xis xresponding xto xthe xpresence xof xthe xinfection. xAlthough xit xwill xbe ximportant xfor xthe xnurse
xto xencourage xthe xclient xto xturn, xcough, xand xfrequently xbreathe xdeeply; xraise xthe xhead xof xthe xbed;
xincrease xoral xfluid xintake; xand xhumidify xthe xoxygen xadministered, xnone xof xthese xactions xwill xbe xas
ximportant xas xassessing xthe xlevel xof xconsciousness. xAlso, xthe xclient xwho xhas xa xpulmonary xinfection
xmay xnot xbe xable xto xcough xeffectively xif xan xarea xof xabscess xis xpresent. x
,DIF: xApplying x
x
5. xA xnurse xis xproviding xcare xafter xauscultating xclients xbreath xsounds. xWhich xassessment xfinding xis
xcorrectly xmatched xto xthe xnurses xprimary xintervention? x
a. Hollow xsounds xare xheard xover xthe xtrachea. xThe xnurse xincreases xthe xoxygen xflow xrate. x
b. Crackles xare xheard xin xbases. xThe xnurse xencourages xthe xclient xto xcough xforcefully. x
c. Wheezes xare xheard xin xcentral xareas. xThe xnurse xadministers xan xinhaled xbronchodilator. xd.
xVesicular xsounds xare xheard xover xthe xperiphery. xThe xnurse xhas xthe xclient xbreathe xdeeply. x-
xCORRECT xANSWER x-ANS: x
Cx
Wheezes xare xindicative xof xnarrowed xairways, xand xbronchodilators xhelp xto xopen xthe xair xpassages.
xHollow xsounds xare xtypically xheard xover xthe xtrachea, xand xno xintervention xis xnecessary. xIf xcrackles
xare xheard, xthe xclient xmay xneed xa xdiuretic. xCrackles xrepresent xa xdeep xinterstitial xprocess, xand
xcoughing xforcefully xwill xnot xhelp xthe xclient xexpectorate xsecretions. xVesicular xsounds xheard xin xthe
xperiphery xare xnormal xand xrequire xno xintervention. x
DIF: xApplying x
x
6. xA xnurse xobserves xthat xa xclients xanteroposterior x(AP) xchest xdiameter xis xthe xsame xas xthe xlateral
xchest xdiameter. xWhich xquestion xshould xthe xnurse xask xthe xclient xin xresponse xto xthis xfinding? x
a. Are xyou xtaking xany xmedications xor xherbal xsupplements? x
b. Do xyou xhave xany xchronic xbreathing xproblems? x
c. How xoften xdo xyou xperform xaerobic xexercise? x
d. What xis xyour xoccupation xand xwhat xare xyour xhobbies? x- xCORRECT xANSWER x-ANS: xB x
The xnormal xchest xhas xa xlateral xdiameter xthat xis xtwice xas xlarge xas xthe xAP xdiameter. xWhen xthe xAP
xdiameter xapproaches xor xexceeds xthe xlateral xdiameter, xthe xclient xis xsaid xto xhave xa xbarrel xchest.
xMost xcommonly, xbarrel xchest xoccurs xas xa xresult xof xa xlong-term xchronic xairflow xlimitation xproblem,
xsuch xas xchronic xobstructive xpulmonary xdisease xor xsevere xchronic xasthma. xIt xcan xalso xbe xseen xin
xpeople xwho xhave xlived xat xa xhigh xaltitude xfor xmany xyears. xTherefore, xan xAP xchest xdiameter xthat xis
xthe xsame xas xthe xlateral xchest xdiameter xshould xbe xrechecked xbut xis xnot xas xindicative xof xunderlying
xdisease xprocesses xas xan xAP xdiameter xthat xexceeds xthe xlateral xdiameter. xMedications, xherbal
xsupplements, xand xaerobic xexercise xare xnot xassociated xwith xa xbarrel xchest. xAlthough xoccupation xand
xhobbies xmay xexpose xa xclient xto xirritants xthat xcan xcause xchronic xlung xdisorders xand xbarrel xchest, x
x
, Test xBank x- xMedical-Surgical xNursing: xConcepts xfor xInterprofessional xCollaborative xCare x9e
215 x xasking xabout xchronic xbreathing xproblems xis xmore xdirect xand xshould xbe xasked xfirst.
x
DIF: xApplying x
x
x
7. xA xnurse xis xassessing xa xclient xwho xis xrecovering xfrom xa xlung xbiopsy. xWhich xassessment xfinding
xrequires ximmediate xaction? x
a. Increased xtemperature x
b. Absent xbreath xsounds x
c. Productive xcough x
d. Incisional xdiscomfort x- xCORRECT xANSWER x-ANS: xB x
Absent xbreath xsounds xmay xindicate xthat xthe xclient xhas xa xpneumothorax, xa xserious xcomplication
after xa xneedle xbiopsy xor xopen xlung xbiopsy. xThe xother xmanifestations xare xnot xlife xthreatening.
x
DIF: xApplying x
x
x
8. xA xnurse xis xcaring xfor xa xclient xwho xis xscheduled xto xundergo xa xthoracentesis. xWhich xintervention
xshould xthe xnurse xcomplete xprior xto xthe xprocedure? x
a. Measure xoxygen xsaturation xbefore xand xafter xa x12-minute xwalk. x
b. Verify xthat xthe xclient xunderstands xall xpossible xcomplications. x
c. Explain xthe xprocedure xin xdetail xto xthe xclient xand xthe xfamily. x x
d. Validate xthat xinformed xconsent xhas xbeen xgiven xby xthe xclient. x- xCORRECT xANSWER x-ANS: xD x
A xthoracentesis xis xan xinvasive xprocedure xwith xmany xpotentially xserious xcomplications. xVerifying xthat
xthe xclient xunderstands xcomplications xand xexplaining xthe xprocedure xto xbe xperformed xwill xbe xdone
xby xthe xphysician xor xnurse xpractitioner, xnot xthe xnurse. xMeasurement xof xoxygen xsaturation xbefore
xand xafter xa x12minute xwalk xis xnot xa xprocedure xunique xto xa xthoracentesis. x
DIF: xApplying x
x
9. xA xnurse xassesses xa xclient xafter xa xthoracentesis. xWhich xassessment xfinding xwarrants ximmediate
xaction? x x
a. The xclient xrates xpain xas xa x5-10 xat xthe xsite xof xthe xprocedure. x
x x x x
HEALTH NURSING REVIEWED
x x x
QUESTIONS AND ANSWERS x x x x
1. xA xnurse xobtains xthe xhealth xhistory xof xa xclient xwho xis xrecently xdiagnosed xwith xlung xcancer xand
xidentifies xthat xthe xclient xhas xa x60pack-year xsmoking xhistory. xWhich xaction xis xmost ximportant xfor
xthe xnurse xto xtake xwhen xinterviewing xthis xclient? x
a. Tell xthe xclient xthat xhe xneeds xto xquit xsmoking xto xstop xfurther xcancer xdevelopment. x
b. Encourage xthe xclient xto xbe xcompletely xhonest xabout xboth xtobacco xand xmarijuana xuse. xc.
xMaintain xa xnonjudgmental xattitude xto xavoid xcausing xthe xclient xto xfeel xguilty. x
d. xAvoid xgiving xthe xclient xfalse xhope xregarding xcancer xtreatment xand xprognosis. x- xCORRECT
xANSWER x-
ANS: xC x
Smoking xhistory xincludes xthe xuse xof xcigarettes, xcigars, xpipe xtobacco, xmarijuana, xand xother
xcontrolled xsubstances. xBecause xthe xclient xmay xhave xguilt xor xdenial xabout xthis xhabit, xassume xa
xnonjudgmental xattitude xduring xthe xinterview. xThis xwill xencourage xthe xclient xto xbe xhonest xabout xthe
xexposure. xAsk xthe xclient xwhether xany xof xthese xsubstances xare xused xnow xor xwere xused xin xthe xpast.
xAssess xwhether xthe xclient xhas xpassive xexposure xto xsmoke xin xthe xhome xor xworkplace. xIf xthe xclient
xsmokes, xask xfor xhow xlong, xhow xmany xpacks xper xday, xand xwhether xhe xor xshe xhas xquit xsmoking
x(and xhow xlong xago). xDocument xthe xsmoking xhistory xin xpack-years x(number xof xpacks xsmoked xdaily
xmultiplied xby xthe xnumber xof xyears xthe xclient xhas xsmoked). xQuitting xsmoking xmay xnot xstop xfurther
xcancer xdevelopment. xThis xstatement xwould xbe xgiving xthe xclient xfalse xhope, xwhich xshould xbe
xavoided, xbut xis xnot xas ximportant xas xmaintaining xa xnonjudgmental xattitude. x
DIF: xApplying x
x
2. xA xnurse xassesses xa xclient xafter xan xopen xlung xbiopsy. xWhich xassessment xfinding xis xmatched xwith
xthe xcorrect xintervention? x
a. Client xstates xhe xis xdizzy. xNurse xapplies xoxygen xand xpulse xoximetry. x
b. Clients xheart xrate xis x55 xbeatsmin. xNurse xwithholds xpain xmedication. x
c. Client xhas xreduced xbreath xsounds. xNurse xcalls xphysician ximmediately. x
d. Clients xrespiratory xrate xis x18 xbreaths xmin. xNurse xdecreases xoxygen xflow xrate. x- xCORRECT
xANSWER xANS: xC x
,A xpotentially xserious xcomplication xafter xbiopsy xis xpneumothorax, xwhich xis xindicated xby xdecreased xor
xabsent xbreath xsounds. xThe xphysician xneeds xto xbe xnotified ximmediately. xDizziness xafter xthe
xprocedure xis xnot xan xexpected xfinding. xIf xthe xclients xheart xrate xis x55 xbeats xmin, xno xreason xis
xknown xto xwithhold xpain xmedication. xA xrespiratory xrate xof x18 xbreaths x
x
3. xA xnurse xassesses xa xclients xrespiratory xstatus. xWhich xinformation xis xof xhighest xpriority xfor xthe
xnurse xto xobtain? xa. xAverage xdaily xfluid xintake x
b. Neck xcircumference x
c. Height xand xweight x
d. Occupation xand xhobbies x- xCORRECT xANSWER x-ANS: xD x
Many xrespiratory xproblems xoccur xas xa xresult xof xchronic xexposure xto xinhalation xirritants xused xin xa
xclients xoccupation xand xhobbies. xAlthough xit xwill xbe ximportant xfor xthe xnurse xto xassess xthe xclients
xfluid xintake, xheight, xand xweight, xthese xwill xnot xbe xas ximportant xas xdetermining xhis xoccupation xand
xhobbies. x
Determining xthe xclients xneck xcircumference xwill xnot xbe xan ximportant xpart xof xa xrespiratory
xassessment. x
Test xBank x- xMedical-Surgical xNursing: xConcepts xfor xInterprofessional xCollaborative xCare x9e x214
x x DIF: xApplying x
x
4. xA xnurse xis xcaring xfor xan xolder xadult xclient xwho xhas xa xpulmonary xinfection. xWhich xaction xshould
xthe xnurse xtake xfirst? x
a. Encourage xthe xclient xto xincrease xfluid xintake. x
b. Assess xthe xclients xlevel xof xconsciousness. x
c. Raise xthe xhead xof xthe xbed xto xat xleast x45 xdegrees. xd. xProvide xthe xclient xwith xhumidified xoxygen.
x- x
CORRECT xANSWER x-ANS: xB x
Assessing xthe xclients xlevel xof xconsciousness xwill xbe xmost ximportant xbecause xit xwill xshow xhow xthe
xclient xis xresponding xto xthe xpresence xof xthe xinfection. xAlthough xit xwill xbe ximportant xfor xthe xnurse
xto xencourage xthe xclient xto xturn, xcough, xand xfrequently xbreathe xdeeply; xraise xthe xhead xof xthe xbed;
xincrease xoral xfluid xintake; xand xhumidify xthe xoxygen xadministered, xnone xof xthese xactions xwill xbe xas
ximportant xas xassessing xthe xlevel xof xconsciousness. xAlso, xthe xclient xwho xhas xa xpulmonary xinfection
xmay xnot xbe xable xto xcough xeffectively xif xan xarea xof xabscess xis xpresent. x
,DIF: xApplying x
x
5. xA xnurse xis xproviding xcare xafter xauscultating xclients xbreath xsounds. xWhich xassessment xfinding xis
xcorrectly xmatched xto xthe xnurses xprimary xintervention? x
a. Hollow xsounds xare xheard xover xthe xtrachea. xThe xnurse xincreases xthe xoxygen xflow xrate. x
b. Crackles xare xheard xin xbases. xThe xnurse xencourages xthe xclient xto xcough xforcefully. x
c. Wheezes xare xheard xin xcentral xareas. xThe xnurse xadministers xan xinhaled xbronchodilator. xd.
xVesicular xsounds xare xheard xover xthe xperiphery. xThe xnurse xhas xthe xclient xbreathe xdeeply. x-
xCORRECT xANSWER x-ANS: x
Cx
Wheezes xare xindicative xof xnarrowed xairways, xand xbronchodilators xhelp xto xopen xthe xair xpassages.
xHollow xsounds xare xtypically xheard xover xthe xtrachea, xand xno xintervention xis xnecessary. xIf xcrackles
xare xheard, xthe xclient xmay xneed xa xdiuretic. xCrackles xrepresent xa xdeep xinterstitial xprocess, xand
xcoughing xforcefully xwill xnot xhelp xthe xclient xexpectorate xsecretions. xVesicular xsounds xheard xin xthe
xperiphery xare xnormal xand xrequire xno xintervention. x
DIF: xApplying x
x
6. xA xnurse xobserves xthat xa xclients xanteroposterior x(AP) xchest xdiameter xis xthe xsame xas xthe xlateral
xchest xdiameter. xWhich xquestion xshould xthe xnurse xask xthe xclient xin xresponse xto xthis xfinding? x
a. Are xyou xtaking xany xmedications xor xherbal xsupplements? x
b. Do xyou xhave xany xchronic xbreathing xproblems? x
c. How xoften xdo xyou xperform xaerobic xexercise? x
d. What xis xyour xoccupation xand xwhat xare xyour xhobbies? x- xCORRECT xANSWER x-ANS: xB x
The xnormal xchest xhas xa xlateral xdiameter xthat xis xtwice xas xlarge xas xthe xAP xdiameter. xWhen xthe xAP
xdiameter xapproaches xor xexceeds xthe xlateral xdiameter, xthe xclient xis xsaid xto xhave xa xbarrel xchest.
xMost xcommonly, xbarrel xchest xoccurs xas xa xresult xof xa xlong-term xchronic xairflow xlimitation xproblem,
xsuch xas xchronic xobstructive xpulmonary xdisease xor xsevere xchronic xasthma. xIt xcan xalso xbe xseen xin
xpeople xwho xhave xlived xat xa xhigh xaltitude xfor xmany xyears. xTherefore, xan xAP xchest xdiameter xthat xis
xthe xsame xas xthe xlateral xchest xdiameter xshould xbe xrechecked xbut xis xnot xas xindicative xof xunderlying
xdisease xprocesses xas xan xAP xdiameter xthat xexceeds xthe xlateral xdiameter. xMedications, xherbal
xsupplements, xand xaerobic xexercise xare xnot xassociated xwith xa xbarrel xchest. xAlthough xoccupation xand
xhobbies xmay xexpose xa xclient xto xirritants xthat xcan xcause xchronic xlung xdisorders xand xbarrel xchest, x
x
, Test xBank x- xMedical-Surgical xNursing: xConcepts xfor xInterprofessional xCollaborative xCare x9e
215 x xasking xabout xchronic xbreathing xproblems xis xmore xdirect xand xshould xbe xasked xfirst.
x
DIF: xApplying x
x
x
7. xA xnurse xis xassessing xa xclient xwho xis xrecovering xfrom xa xlung xbiopsy. xWhich xassessment xfinding
xrequires ximmediate xaction? x
a. Increased xtemperature x
b. Absent xbreath xsounds x
c. Productive xcough x
d. Incisional xdiscomfort x- xCORRECT xANSWER x-ANS: xB x
Absent xbreath xsounds xmay xindicate xthat xthe xclient xhas xa xpneumothorax, xa xserious xcomplication
after xa xneedle xbiopsy xor xopen xlung xbiopsy. xThe xother xmanifestations xare xnot xlife xthreatening.
x
DIF: xApplying x
x
x
8. xA xnurse xis xcaring xfor xa xclient xwho xis xscheduled xto xundergo xa xthoracentesis. xWhich xintervention
xshould xthe xnurse xcomplete xprior xto xthe xprocedure? x
a. Measure xoxygen xsaturation xbefore xand xafter xa x12-minute xwalk. x
b. Verify xthat xthe xclient xunderstands xall xpossible xcomplications. x
c. Explain xthe xprocedure xin xdetail xto xthe xclient xand xthe xfamily. x x
d. Validate xthat xinformed xconsent xhas xbeen xgiven xby xthe xclient. x- xCORRECT xANSWER x-ANS: xD x
A xthoracentesis xis xan xinvasive xprocedure xwith xmany xpotentially xserious xcomplications. xVerifying xthat
xthe xclient xunderstands xcomplications xand xexplaining xthe xprocedure xto xbe xperformed xwill xbe xdone
xby xthe xphysician xor xnurse xpractitioner, xnot xthe xnurse. xMeasurement xof xoxygen xsaturation xbefore
xand xafter xa x12minute xwalk xis xnot xa xprocedure xunique xto xa xthoracentesis. x
DIF: xApplying x
x
9. xA xnurse xassesses xa xclient xafter xa xthoracentesis. xWhich xassessment xfinding xwarrants ximmediate
xaction? x x
a. The xclient xrates xpain xas xa x5-10 xat xthe xsite xof xthe xprocedure. x
