ATI Assessment of the Respiratory System, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. A client has undergone a thoracentesis. Which assessment finding requires immediate action by the nurse?

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 Potential—Potential 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?

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 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: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

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?

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)

4. 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?

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.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Teaching/Learning

5. When assessing a client’s respiratory status, which information is of highest priority for the nurse to obtain?