Chapter 29: Assessment of the Respiratory System
Terms in this set (20)
A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse?
a. Decreased level of consciousness
c. Increased temperature
d. Slowed respiratory rate
An increased heart rate may indicate that the client is developing a pneumothorax or
hypoxia. Although it is important to note immediately whether the client is experiencing adecreased level of consciousness, increased temperature, or a slowed respiratory rate, none of these is as indicative of a life-threatening complication as tachycardia.
The nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?
a. Client feels "dizzy;" nurse applies oxygen and pulse
b. Client's heart rate is 55 beats/min; nurse withholds pain
c. Client has reduced breath sounds; nurse calls physician
d. Client's respiratory rate is 18 breaths/min; nurse decreases
oxygen flow rate.
A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately.
Dizziness after the procedure is not an expected finding. 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.
The nurse is caring for four clients who had arterial blood gases (ABGs).
Which laboratory value warrants immediate intervention by the nurse?
- of 25 mEq/L
b. SpO2 of 96%
c. pH of 7.38
d. PaCO2 of 48 mm Hg
Although the nurse should note the results of all laboratory work, only a PaCO2 of 48
mm Hg is likely to culminate in serious symptoms for the client. HCO3-, SpO2, and pH levels as assessed would not be life threatening, nor would they be indicative of serious complications that would override the importance of the PaCO2 level.
The nurse is calculating a client's smoking history in pack-years. The
client has recently been diagnosed with lung cancer. Which is the nurse's priority
intervention during the interview?
a. Encourage the client to quit smoking to stop further cancer
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.
Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other
controlled substances. 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 a 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). 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
When assessing a client's 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
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. Determining the client's neck circumference will not be an important part of a respiratory assessment.
The nursing assistant reports to the nurse that an African-American client's pulse oximetry reading is 93%. The client has no complaints. Which action by the nurse is most appropriate?
a. Replace the sensor probe of the oximeter.
b. Place the probe on another finger.
c. Assess other signs of respiratory adequacy.
d. Prepare to obtain arterial blood gases.
Normal pulse oximetry readings are 95% to 100%. However, people with dark skin can
have readings that are 3% to 5% lower owing to the darker coloration of the nail bed. The nurse should assess other signs of respiratory adequacy because this may be a normal finding for this client.
The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client?
a. Encouraging the client to increase fluid intake
b. Assessing the client's level of consciousness
c. Raising the head of the bed to at least 45 degrees
d. Providing the client with humidified oxygen
Assessing the client's 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 breathe deeply frequently; to raise the head of the bed; and to 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.
The nurse is assessing a client's breath sounds. Which assessment finding has been correctly linked to the nurse's primary intervention?
a. Hollow sounds heard over trachea; increase oxygen flow
b. Crackles heard in bases; have the client cough forcefully.
c. Wheezes heard in central areas; administer inhaled
d. Vesicular sounds heard over the periphery; have the client
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no interventions.
A client has a long-standing history of chronic obstructive pulmonary
disease (COPD). Which laboratory finding does the nurse correlate with this condition?
a. White blood cell count, 7500/mm3
b. Hemoglobin, 22 g/dL
c. Neutrophils, 6000/ mm3
d. Monocytes, 600/mm3
Normal hemoglobin for a female is 12 to 16 g/dL. Clients with COPD have chronic
hypoxia, which stimulates the production of erythropoietin and thus raises the red bloodcell count and hemoglobin and hematocrit levels. All other values are normal.
The nurse is caring for several clients on a respiratory unit. Which client does the nurse see first?
a. Older adult with an SaO2 of 96% on room air
b. Adult client with an SaO2 of 94% on 2 L/min
c. Young adult with an arterial oxygen level of 85%
d. Young adult with an arterial oxygen level of 94%
The young adult with an impaired arterial oxygen level should be seen first. A level of 90% to 100% is a normal level for this age-group. The older adult with a pulse oxygen of 96% is within normal limits, as is an adult with a pulse oxygen of 94%. An arterial oxygen level of 94% would also be seen as normal.
A client with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic with increased cough and low-grade temperature. Which question
by the nurse elicits the most useful information?
a. "How long have you been sick?"
b. "Has your sputum changed color?"
c. "Is anyone else in your house sick?"
d. "Do you take any medications?"
Clients with COPD usually have a productive cough. If the color has changed, that is a noteworthy finding. If the client's sputum is yellow or green, this may indicate a pulmonary infection. The other questions are also appropriate to ask but will not help in gathering information specific to a pulmonary problem.
A client tells the nurse that he usually expectorates about 2 ounces of thin, clear, colorless sputum each day, mostly in the morning after getting out of bed. What is the nurse's initial action after gaining this information?
a. Ask the client to provide a morning sputum sample for
b. Obtain a specimen of the sputum in a sterile container for
c. Monitor for an increase in sputum production or a change
d. Notify the health care provider and prepare the client for
Sputum production is a normal function of the respiratory tract. Most healthy people produce about 90 mL of sputum/day. This sputum should be thin, clear, and odorless, and should have minimal or no color. The nurse's only action should be to monitor the client
for an increase in sputum production or a change in color. It will not be necessary at this time to obtain a specimen for analysis or to prepare for a bronchoscopy.
The nurse observes that a client's anteroposterior (AP) chest diameter is the same as his lateral chest diameter. What is the nurse's most important question for the
client in response to this finding?
a. No questions are needed regarding this normal finding.
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?"
The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, 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 obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many
years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter.
A client with long-standing pulmonary problems is classified as having class III dyspnea. Based on this classification, what type of assistance does the nurse
anticipate providing for ADLs?
a. Dyspnea is minimal and the client requires no additional assistance.
b. The client may require rest periods during performance of
c. The client requires assistance for some but not all tasks.
d. Owing to severe dyspnea, this client cannot participate in
Class III dyspnea occurs during usual activities, such as showering, but the client does not require assistance from others. The client may need to rest during activities. A client with class I dyspnea would likely need no assistance. A client with class IV dyspnea may require assistance for some but not all tasks. A client with class V dyspnea cannot
participate in any self-care.
A postoperative client has an oxygen saturation of 96% but is pale and dyspneic and says, "I can't get enough air!" The client's lung sounds are clear. Which action by the nurse is most appropriate?
a. Call the physician and request a hemoglobin and hematocrit level.
b. Notify respiratory therapy and request a breathing treatment.
c. Encourage the client to cough and deep breathe 10 times each hour.
d. Take the client's temperature and give antipyretics if needed.
A normal pulse oximetry reading is 95% to 100%. Pulse oximetry measures the percent of hemoglobin saturated with oxygen. However, if the client's hemoglobin level is low, the pulse oximetry reading may not correlate with his or her condition. A postoperative
client is at risk for bleeding, so the nurse should request a hemoglobin and hematocrit level. Respiratory treatment is not indicated. Coughing and deep breathing are appropriate but are not the priority. Monitoring for and treating fevers is also appropriate but is not the priority.
A client had a flexible bronchoscopy 2 hours ago and has become mildly
cyanotic despite the application of oxygen. When giving change-of-shift report, which question by the oncoming nurse elicits the most useful information?
a. "How long was the client sedated for the procedure?"
b. "Were the oximetry readings during the test normal?"
c. "Are you sure the client was NPO before the bronchoscopy?"
d. "What kind of topical anesthetic was used on the client?"
Benzocaine spray can be used as a topical anesthetic before bronchoscopy to numb the throat. However, its use is associated with methemoglobinemia. Methemoglobin does not carry oxygen, and a clue to this problem is increasing cyanosis refractory to oxygen. Chocolate brown blood is another characteristic of this problem. The other options are all appropriate but are not the priority.
A client is scheduled to undergo a thoracentesis. What is the nurse's
a. Measure oxygen saturation before and after a 12-minutewalk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Verify that informed consent has been given by the client.
A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.
The nurse is caring for a client after a thoracentesis. Which assessment
finding by the nurse warrants immediate action?
a. Client rates pain as 5/10 at the site of the procedure.
b. Small amount of drainage is noted from the site.
c. Pulse oximetry is 93% on 2 liters of oxygen.
d. Trachea is deviated toward opposite side of the neck.
A deviated trachea is a manifestation of a tension pneumothorax, which is a medical
emergency. The other findings are normal or near-normal.
A client had a bronchoscopy 2 hours ago and is requesting water to drink. Which action by the nurse is most appropriate?
a. Call the physician and request an order for food and water.
b. Give the client ice chips instead of a drink of water.
c. Assess the client's gag reflex before giving anything.
d. Let the client have a small sip to see whether he or she can
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
A client is scheduled for pulmonary function tests (PFTs) in the morning.
The nurse calls the client to teach about the procedure. Which statement by the client indicates a need for further teaching?
a. "I should not smoke for at least 6 hours before the test."
b. "PFTs can determine whether my lung problem has gotten worse."
c. "I should use my inhaler anytime during the test if I need it."
d. "If I get really short of breath, I'll tell the technician."
Bronchodilators may need to be held before PFTs. The client should not plan to use them at any time during the test if he or she experiences dyspnea. The other options show adequate understanding.