NURS 204 - Exam 2 - Chapter 27
Questions With Accurate Answers
Ch. 27
1. A nurse obtains the health history of a client who is recently diagnosed with lung
cancer and identifies that the client has a 60pack-year smoking history. Which action is
most important for the nurse to take when interviewing this client?
a. Tell the client that he 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. -
SOLVED ANSWER-ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and
other controlled substances. Because the client may have guilt or denial about this
habit, assume a nonjudgmental attitude during the interview. This will encourage the
client to be honest about the exposure. Ask the client whether any of these substances
are used now or were used in the past. Assess whether the client has passive exposure
to smoke in the home or workplace. If the client smokes, ask for how long, how many
packs per day, and whether he or she has quit smoking (and how long ago). Document
the smoking history in pack-years (number of packs smoked daily multiplied by the
number of years the client has smoked). Quitting smoking may not stop further 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.
Ch. 27
3. A nurse assesses a clients respiratory status. Which information is of highest priority
for the nurse to obtain?
a. Average daily fluid intake
, b. Neck circumference
c. Height and weight
d. Occupation and hobbies - SOLVED ANSWER-ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants
used in a clients occupation and hobbies. Although it will be important for the nurse to
assess the clients fluid intake, height, and weight, these will not be as important as
determining his occupation and hobbies. Determining the clients neck circumference will
not be an important part of a respiratory assessment.
Ch. 27
4. A nurse is caring for an older adult client who has a pulmonary infection. Which
action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the clients level of consciousness.
c. Raise the head of the bed to at least 45 degrees.
d. Provide the client with humidified oxygen. - SOLVED ANSWER-ANS: B
Assessing the clients level of consciousness will be most important because it will show
how the client is responding to the presence of the infection. Although it will be
important for the nurse to encourage the client to turn, cough, and frequently breathe
deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen
administered, none of these actions will be as important as assessing the level of
consciousness. Also, the client who has a pulmonary infection may not be able to cough
effectively if an area of abscess is present.
Ch. 27
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is
matched with the correct intervention?
a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
Questions With Accurate Answers
Ch. 27
1. A nurse obtains the health history of a client who is recently diagnosed with lung
cancer and identifies that the client has a 60pack-year smoking history. Which action is
most important for the nurse to take when interviewing this client?
a. Tell the client that he 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. -
SOLVED ANSWER-ANS: C
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and
other controlled substances. Because the client may have guilt or denial about this
habit, assume a nonjudgmental attitude during the interview. This will encourage the
client to be honest about the exposure. Ask the client whether any of these substances
are used now or were used in the past. Assess whether the client has passive exposure
to smoke in the home or workplace. If the client smokes, ask for how long, how many
packs per day, and whether he or she has quit smoking (and how long ago). Document
the smoking history in pack-years (number of packs smoked daily multiplied by the
number of years the client has smoked). Quitting smoking may not stop further 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.
Ch. 27
3. A nurse assesses a clients respiratory status. Which information is of highest priority
for the nurse to obtain?
a. Average daily fluid intake
, b. Neck circumference
c. Height and weight
d. Occupation and hobbies - SOLVED ANSWER-ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants
used in a clients occupation and hobbies. Although it will be important for the nurse to
assess the clients fluid intake, height, and weight, these will not be as important as
determining his occupation and hobbies. Determining the clients neck circumference will
not be an important part of a respiratory assessment.
Ch. 27
4. A nurse is caring for an older adult client who has a pulmonary infection. Which
action should the nurse take first?
a. Encourage the client to increase fluid intake.
b. Assess the clients level of consciousness.
c. Raise the head of the bed to at least 45 degrees.
d. Provide the client with humidified oxygen. - SOLVED ANSWER-ANS: B
Assessing the clients level of consciousness will be most important because it will show
how the client is responding to the presence of the infection. Although it will be
important for the nurse to encourage the client to turn, cough, and frequently breathe
deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen
administered, none of these actions will be as important as assessing the level of
consciousness. Also, the client who has a pulmonary infection may not be able to cough
effectively if an area of abscess is present.
Ch. 27
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is
matched with the correct intervention?
a. Client states he is dizzy. Nurse applies oxygen and pulse oximetry.
