29

Chapter 29: Assessment of the Respiratory System
Test Bank
MULTIPLE CHOICE
1. A client has undergone a thoracentesis. Which assessment finding requires immediate action
by the nurse?
Decreased level of consciousness
Tachycardia
Increased temperature
Slowed respiratory rate
a.
b.
c.
d.
ANS: B
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 a decreased
level of consciousness, increased temperature, or a slowed respiratory rate, none of these is as
indicative of a life-threatening complication as tachycardia.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
2. The nurse assesses a client after an open lung biopsy. Which assessment finding is matched
with the correct intervention?

Client feels dizzy; nurse applies oxygen and pulse oximeter.
Clients heart rate is 55 beats/min; nurse withholds pain medication.
Client has reduced breath sounds; nurse calls physician immediately.
Clients respiratory rate is 18 breaths/min; nurse decreases oxygen flow rate.
a.
b.
c.
d.
ANS: C
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 clients 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.
REF: N/A
MSC: Integrated Process: Nursing Process (Implementation)
3. The nurse is caring for four clients who had arterial blood gases (ABGs). Which laboratory
value warrants immediate intervention by the nurse?

HCO3 of 25 mEq/L
SpO2 of 96%
pH of 7.38
PaCO2 of 48 mm Hg
a.
b.
c.
d.
ANS: D
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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory
Values)
4. The nurse is calculating a clients smoking history in pack-years. The client has recently been
diagnosed with lung cancer. Which is the nurses priority intervention during the interview?
a. Encourage the client 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 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.
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Teaching/Learning
5. When assessing a clients respiratory status, which information is of highest priority for the
nurse to obtain?
Average daily fluid intake
Neck circumference
Height and weight
Occupation and hobbies
a.
b.
c.
d.
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.
DIF: Cognitive Level: Knowledge/Remembering
REF: p. 548
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
6. The nursing assistant reports to the nurse that an African-American clients pulse oximetry
reading is 93%. The client has no complaints. Which action by the nurse is most appropriate?
a.
b.
c.
d.
Replace the sensor probe of the oximeter.

Place the probe on another finger.
Assess other signs of respiratory adequacy.
Prepare to obtain arterial blood gases.
ANS: C
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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests)
MSC:
Integrated Process: Nursing Process (Analysis)
7. 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 clients level of consciousness
c. Raising the head of the bed to at least 45 degrees
d. Providing the client with humidified oxygen
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 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.
DIF: Cognitive Level: Comprehension/Understanding
REF: Chart 29-1, p. 549
TOP: Client Needs Category: Health Promotion and Maintenance (Aging Process)
8. The nurse is assessing a clients breath sounds. Which assessment finding has been correctly
linked to the nurses primary intervention?

Hollow sounds heard over trachea; increase oxygen flow rate.
Crackles heard in bases; have the client cough forcefully.
Wheezes heard in central areas; administer inhaled bronchodilator.
Vesicular sounds heard over the periphery; have the client breathe deeply.
a.
b.
c.
d.
ANS: C
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.
REF: N/A
MSC: Integrated Process: Nursing Process (Analysis)
9. A client has a long-standing history of chronic obstructive pulmonary disease (COPD). Which
laboratory finding does the nurse correlate with this condition?

White blood cell count, 7500/mm3
Hemoglobin, 22 g/dL
Neutrophils, 6000/ mm3
Monocytes, 600/mm3
a.
b.
c.
d.
ANS: B
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 blood cell count and
hemoglobin and hematocrit levels. All other values are normal.
REF: Chart 29-3, p. 557
Values)
10. The nurse is caring for several clients on a respiratory unit. Which client does the nurse see
first?
Older adult with an SaO2 of 96% on room air
Adult client with an SaO2 of 94% on 2 L/min
Young adult with an arterial oxygen level of 85%
Young adult with an arterial oxygen level of 94%
a.
b.
c.
d.
ANS: C
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.
REF: Chart 29-3, p. 557
Values)
11. 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?
ANS: B
Clients with COPD usually have a productive cough. If the color has changed, that is a
noteworthy finding. If the clients 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.
REF: N/A
12. 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 nurses initial
action after gaining this information?
a. Ask the client to provide a morning sputum sample for laboratory analysis.
b. Obtain a specimen of the sputum in a sterile container for culture.
c. Monitor for an increase in sputum production or a change in color.
d. Notify the health care provider and prepare the client for possible bronchoscopy.
ANS: C
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 nurses 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.
REF: N/A
Alterations in Body Systems)
13. The nurse observes that a clients anteroposterior (AP) chest diameter is the same as his lateral
chest diameter. What is the nurses 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?
ANS: B
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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialSystem-Specific
Assessments)
14. 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 ADLs.
c. The client requires assistance for some but not all tasks.
d. Owing to severe dyspnea, this client cannot participate in any self-care.
ANS: B
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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Planning)
15. A postoperative client has an oxygen saturation of 96% but is pale and dyspneic and says, I
cant get enough air! The clients 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 clients temperature and give antipyretics if needed.
ANS: A
A normal pulse oximetry reading is 95% to 100%. Pulse oximetry measures the percent of
hemoglobin saturated with oxygen. However, if the clients 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.
REF: N/A
Complications from Surgical Procedures and Health Alterations)
16. 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?
ANS: D
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.
REF: N/A
17. A client is scheduled to undergo a thoracentesis. What is the nurses priority intervention?
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. Verify that informed consent has been given by the client.
ANS: D
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.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareInformed
Consent)
MSC: Integrated Process: Communication and Documentation
18. The nurse is caring for a client after a thoracentesis. Which assessment finding by the nurse
warrants immediate action?

Client rates pain as 5/10 at the site of the procedure.
Small amount of drainage is noted from the site.
Pulse oximetry is 93% on 2 liters of oxygen.
Trachea is deviated toward opposite side of the neck.
a.
b.
c.
d.
ANS: D
A deviated trachea is a manifestation of a tension pneumothorax, which is a medical

emergency. The other findings are normal or near-normal.
REF: N/A
19. A client had a bronchoscopy 2 hours ago and is requesting water to drink. Which action by the
nurse is most appropriate?

Call the physician and request an order for food and water.
Give the client ice chips instead of a drink of water.
Assess the clients gag reflex before giving anything.
Let the client have a small sip to see whether he or she can swallow.
a.
b.
c.
d.
ANS: C
The topical anesthetic used during the procedure will have affected the clients gag reflex.
Before allowing the client anything to eat or drink, the nurse must check for the return of this
reflex.
REF: N/A
20. 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, Ill tell the technician.
ANS: C
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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests)
MSC:
Integrated Process: Teaching/Learning

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Chapter 29: Assessment of the Respiratory System

with the correct intervention?

A potentially serious complication after biopsy is pneumothorax, which is indicated by

value warrants immediate intervention by the nurse?

Replace the sensor probe of the oximeter.

is a priority with this client?

linked to the nurses primary intervention?

laboratory finding does the nurse correlate with this condition?

A thoracentesis is an invasive procedure with many potentially serious complications.

warrants immediate action?

A deviated trachea is a manifestation of a tension pneumothorax, which is a medical

nurse is most appropriate?

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