Chapter 24: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
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 prognosis.
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.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment
MSC: Client Needs Category: Psychosocial Integrity
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
d.
immediately.
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.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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 the client in response to this finding?
a. “Are you taking any medications or herbal supplements?”
b. “Do you have any chronic breathing problems?”
c. “How often do you perform aerobic exercise?”
d. “What is your occupation and what are your hobbies?”
ANS: B
The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral (side-to-side) diameter. This ratio
normally is about 1:1.5. When the AP diameter approaches the lateral diameter, and the ratio is 1:1, the client is said to have a
barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic
emphysema. It can also be seen in people who have lived at a high altitude for many years. Medications, herbal supplements, and
aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can
cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and would be asked first.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
Copyright © 2021, Elsevier Inc. All rights reserved.
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5. A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds are absent. While another nurse calls
the Rapid Response Team, what action by the nurse takes is most important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site.
ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung
biopsy. The nurse would first obtain a pulse oximetry reading and perform other respiratory assessments. Temperature is not a
priority. The nurse can ask about other symptoms while conducting the assessment. The nurse would assess the biopsy site and/or
dressings, but this is not the first action.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the
procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.
ANS: D
A thoracentesis is an invasive procedure with many potentially serious complications. The nurse would ensure signed informed
consent has been obtained. Verifying that the client understands complications and explaining the procedure to be performed will
be done by the primary health care provider, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is
not a procedure unique to a thoracentesis.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. 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
8. 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
9. 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
Copyright © 2021, Elsevier Inc. All rights reserved.
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10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client’s
teaching?
a. “Make a list of reasons why smoking is a bad habit.”
b. “Rise slowly when getting out of bed in the morning.”
c. “Smoking while taking this medication will increase your risk of a stroke.”
d. “Stopping this medication suddenly increases your risk for a heart attack.”
ANS: C
Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses would
teach clients not to smoke while taking these drugs. The nurse would encourage the client to make a list of reasons for stopping the
habit but would not phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement therapy. Stopping
suddenly does not increase the risk of heart attack.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory assessment, Smoking cessation
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous
cyanosis even with oxygen therapy. What action would the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client’s peripheral pulses.
d. Obtain blood and sputum cultures.
ANS: B
Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an adverse effect of benzocaine spray. This
condition can lead to death. The nurse would notify the Rapid Response Team to provide advanced care. An albuterol treatment
would not address the client’s oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat the
client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
12. A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action would the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler position.
d. Administer prescribed albuterol.
ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx.
The nurse would document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client’s
position because the finding is normal.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify
as adverse effects of this medication? (Select all that apply.)
a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Manic behavior
e. Increased thirst
f. Orangish urine
ANS: A, D
Varenicline has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse would assess for
changes in behavior and thought processes, including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and
orange-colored urine are not adverse effects of this medication. Decreased cravings are a therapeutic response to this medication.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Medication administration, Medication side effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
Copyright © 2021, Elsevier Inc. All rights reserved.
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2. While obtaining a client’s health history, the client states, “I am allergic to avocados, molds, and grass.” Which responses by the
nurse are best? (Select all that apply.)
a. “What happens when you are exposed to those things?
b. “How do you treat these allergies?”
c. “When was the last time you ate foods containing avocados?”
d. “I will document this in your record so all so everyone knows.”
e. “Have you ever been in the hospital after an allergic response?”
f. “How do manage to avoid grass and mold?”
ANS: A, B, D, E
Nurses would assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse would also
document the allergies in a prominent place in the client’s medical record. Asking about the last time the client ate avocados does
not provide any pertinent information for the client’s plan of care. Asking how a client manages to avoid environmental allergies in
this fashion also does not provide any pertinent information.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Allergies
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would
the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.)
a. “I held the client’s morning bronchodilator medication.”
b. “The client is ready to go down to radiology for this examination.”
c. “Physical therapy states the client can run on a treadmill.”
d. “I advised the client not to smoke for 6 hours prior to the test.”
e. “The client is alert and can follow your commands.”
ANS: A, D, E
To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6
hours (depending on the suspected cause), the client did not smoke within 6 to 8 hours prior to the test, and the client can follow
basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside or the
respiratory lab. A treadmill is not used for this test.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client’s teaching?
(Select all that apply.)
a. “Find an activity that you enjoy and will keep your hands busy.”
b. “Keep snacks like potato chips on hand to nibble on.”
c. “Identify a consequence for yourself in case you backslide.”
d. “Drink at least eight glasses of water each day.”
e. “Make a list of reasons you want to stop smoking.”
f. “Set a quit date and stick to it.”
ANS: A, D, E, F
The nurse would teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy
snacks on hand to nibble on, to drink at least eight glasses of water each day, to make a list of reasons for quitting smoking, and to
set a firm quit date and stick to it. The nurse would also encourage the client not to be upset if he or she backslides and has a
cigarette but to try to determine what conditions caused him or her to smoke.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Smoking cessation, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
5. A nurse is assessing a client’s history of particular matter exposure. What questions are consistent with the I PREPARE tool?
(Select all that apply.)
a. Investigate all history of known exposures.
b. Determine if breathing problems are worse at work.
c. Ask the client what type of heating is in the home.
d. Gather details about the geographic location of the client’s home.
e. Have client list all previous jobs and work experiences.
f. Assess what hobbies the client and family enjoy.
ANS: A, B, C, D, E, F
All questions are appropriate for the I PREPARE model of particulate matter exposure. The R and final E stands for
resources/referrals and educate.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory assessment, Smoking cessation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
Copyright © 2021, Elsevier Inc. All rights reserved.
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6. A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential
pneumothorax? (Select all that apply.)
a. Bradycardia
b. New-onset cough
c. Purulent sputum
d. Tachypnea
e. Pain with respirations
f. Rapid, shallow respirations
ANS: B, D, E
Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough, and pain that is worse at the end of
inhalation and the end of exhalation on the affected side. Additional symptoms include trachea slanted to the unaffected side,
cyanosis, and the affected side of the chest that does not move in and out with respirations. Purulent sputum is a symptom of
infection.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What
actions would the nurse take? (Select all that apply.)
a. Provide a clear liquid breakfast.
b. Verify that the informed consent was obtained.
c. Document the client’s allergies.
d. Review laboratory results.
e. Hold the client’s bronchodilator.
f. Monitor the client for at least 24 hours afterwards.
ANS: B, C, D, F
Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep the client NPO for 4 to 8 hours prior
to the procedure or per agency policy to prevent aspiration, document allergies, and review laboratory results including complete
blood count and bleeding times. There is no reason to hold the client’s bronchodilator prior to this procedure. The nurse will
monitor the client at least every 4 hours for 24 hours.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
Copyright © 2021, Elsevier Inc. All rights reserved.
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