59 Questions
Which of the following is the most important consideration for a nurse when providing care to a client after an open lung biopsy?
Closely monitoring the client for signs of a potentially serious complication, such as pneumothorax
A nurse assesses a client's respiratory status after an open lung biopsy and notes reduced breath sounds. Which of the following is the most appropriate nursing intervention?
Call the physician immediately to report the findings
A client states they are feeling dizzy after an open lung biopsy. Which of the following nursing interventions is most appropriate?
Apply oxygen and monitor the client's pulse oximetry
A client's heart rate is 55 beats per minute after an open lung biopsy. Which of the following nursing interventions is most appropriate?
Withhold pain medication due to the client's decreased heart rate
A client's respiratory rate is 18 breaths per minute after an open lung biopsy. Which of the following nursing interventions is most appropriate?
Decrease the oxygen flow rate to improve the client's respiratory status
Which of the following is the most important principle to consider when providing care to a client after an open lung biopsy?
Closely monitoring the client for signs of a potentially serious complication, such as pneumothorax
What is the main purpose of obtaining informed consent from a client before a thoracentesis?
To verify the client's understanding of potential complications
Who is responsible for explaining the potential complications and the procedure details of a thoracentesis to the client?
The physician or nurse practitioner
What does a deviated trachea following a thoracentesis indicate?
A possible tension pneumothorax
Which assessment finding in a client after a thoracentesis requires the nurse's immediate attention?
Deviated trachea toward the opposite side of the neck
What is an expected oxygen saturation level for a client on 2 liters of oxygen post-thoracentesis?
98%
If a client who had a bronchoscopy requests a drink of water 2 hours post-procedure, what should be the nurse's next action?
Consult with the physician before giving water
Which of the following assessment findings would require immediate action for a client recovering from a lung biopsy?
Absence of breath sounds on auscultation
Prior to performing a thoracentesis, which intervention should the nurse prioritize?
Obtaining informed consent from the client or their legal representative
Which of the following assessment findings would indicate a potential chronic lung disorder or barrel chest in a client?
All of the above
In assessing a client for potential chronic lung disorders, which approach should the nurse prioritize?
Directly asking the client about any chronic breathing problems they may experience
Which of the following assessment findings would be considered a life-threatening complication after a lung biopsy procedure?
Absence of breath sounds on auscultation
In preparing a client for a thoracentesis procedure, which of the following interventions should the nurse prioritize?
Obtaining informed consent from the client or their legal representative
Which statement is the most accurate regarding the nurse's collaboration with food services in this scenario?
The nurse should collaborate with food services to ensure no avocados are placed on the client's meal trays.
Which statement regarding the nurse's communication with the respiratory therapist is INCORRECT?
The nurse should tell the respiratory therapist that physical therapy states the client can run on a treadmill during the PFTs.
What is the LEAST relevant information the nurse should communicate to the respiratory therapist prior to the pulmonary function tests?
The client is ready to go down to radiology for this examination.
Which statement best describes the nurse's role in collaborating with the respiratory therapist for the pulmonary function tests?
The nurse should communicate relevant information to the respiratory therapist to ensure the tests are accurate.
What is the LEAST important piece of information the nurse should communicate to the respiratory therapist prior to the pulmonary function tests?
Physical therapy states the client can run on a treadmill.
Which statement best describes the purpose of the nurse's collaboration with the respiratory therapist prior to the pulmonary function tests?
To ensure the client is prepared and the tests can be conducted accurately.
Which of the following should NOT be included in the teaching for a client interested in smoking cessation?
Establishing a punitive measure for lapses in smoking cessation
According to the information provided, which of the following snacks would be appropriate for a client attempting smoking cessation?
Fresh fruits and vegetables
Which of the following strategies is NOT recommended for a client interested in smoking cessation?
Consuming high-calorie snacks to curb cravings
According to the information provided, which of the following is an appropriate approach for a nurse when a client experiences a lapse in smoking cessation?
Encourage the client not to be discouraged by the lapse
Which of the following is the LEAST important reason for a client to create a list of motivations for quitting smoking?
To comply with workplace or societal smoking restrictions
According to the information provided, which of the following combinations of strategies would be MOST effective for a client attempting smoking cessation?
Drinking at least 8 glasses of water daily, creating a list of reasons for quitting, and engaging in enjoyable activities
Which assessment finding would indicate the nurse's primary intervention should be to administer an inhaled bronchodilator?
Wheezes are heard in central lung areas
What is the MOST important consideration for the nurse when providing care to a client with a pulmonary infection?
Assessing the level of consciousness
Which statement regarding the nurse's collaboration with the respiratory therapist is MOST accurate?
The nurse should prioritize communicating the client's assessment findings and medication regimen
Which nursing intervention is MOST appropriate for a client who has reduced breath sounds after an open lung biopsy?
Have the client breathe deeply
What is the MAIN purpose of obtaining informed consent from a client before a thoracentesis procedure?
To ensure the client understands the procedure details
Which assessment finding would require the nurse's IMMEDIATE attention after a thoracentesis procedure?
Deviated trachea
Which of the following is the MOST important nursing intervention to help maximize functioning of the respiratory system and prevent infection in a client at high risk for a pulmonary infection?
Encouraging regular pulmonary hygiene and activities to maintain health and fitness
A client is recovering from a thoracentesis procedure. Which of the following assessment findings would require the nurse's IMMEDIATE attention?
Reduced breath sounds
A client is recovering from an open lung biopsy. Which of the following assessment findings would be considered a LIFE-THREATENING complication?
Reduced breath sounds
A client is interested in smoking cessation. Which of the following strategies would be LEAST effective for this client?
Creating a list of motivations for quitting smoking
A client is recovering from a thoracentesis procedure. Which of the following oxygen saturation levels would be considered APPROPRIATE for this client on 2 liters of oxygen?
92%
In assessing a client's smoking history, what is the significance of calculating pack-years?
It quantifies the cumulative exposure to tobacco smoke over time.
When interviewing a client with a significant smoking history, which approach should the nurse prioritize?
Maintain a non-judgmental attitude to encourage honest disclosure.
Which of the following substances should be included in a comprehensive smoking history?
Cigarettes, cigars, pipe tobacco, marijuana, and electronic cigarettes
In addition to assessing active smoking, what other factor should the nurse consider when evaluating a client's respiratory health?
All of the above
If a client discloses a history of smoking but expresses denial or guilt, what is the most appropriate nursing intervention?
Maintain a non-judgmental attitude and create a supportive environment.
What is the primary purpose of documenting a client's smoking history in pack-years?
To estimate the client's risk for developing respiratory diseases.
Which assessment finding would indicate a potential barrel chest in the client described?
An anteroposterior chest diameter equal to the lateral chest diameter
What is the most likely underlying cause of the described chest finding?
Long-term chronic airflow limitation
If the nurse rechecks the client's chest measurements and finds the anteroposterior diameter exceeds the lateral diameter, what should be the next step?
Recommend chest x-ray and pulmonary function tests
Which additional assessment would be most relevant for a client with a potential barrel chest?
Checking for clubbed nails
If the client confirms having a chronic breathing problem, which intervention should the nurse prioritize?
Referring to a respiratory therapist
Which statement about the described chest finding is most accurate?
It warrants further investigation
What should a nurse emphasize to a client interested in smoking cessation regarding keeping snacks on hand?
Choose low-fat, healthy snacks like fruits or vegetables
Which approach should a nurse take when teaching a client interested in smoking cessation about managing setbacks?
Accept that setbacks are normal and part of the process
What is the most crucial reason for a nurse to encourage a client interested in smoking cessation to drink at least eight glasses of water daily?
It helps flush out toxins from the body
Why should a nurse recommend a client interested in smoking cessation to find an activity that keeps their hands busy?
To distract from cravings and replace the smoking habit
Which behavior should a nurse discourage in a client interested in smoking cessation related to reasons for quitting smoking?
Relying solely on external pressure to stop smoking
Which recommendation is most appropriate for a nurse to give to a client interested in smoking cessation regarding creating a list of reasons to quit?
Incorporate both personal and external motivators on the list
Study Notes
Smoking Cessation
- To help a client quit smoking, the nurse should teach them to:
- Find an activity that keeps their hands busy
- Keep healthy snacks on hand to nibble on
- Drink at least 8 glasses of water each day
- Make a list of reasons for quitting smoking
Assessment and Diagnostic Examination
- After an open lung biopsy, the nurse should:
- Assess for decreased or absent breath sounds, which may indicate pneumothorax
- Notify the physician immediately if decreased breath sounds are detected
- When assessing a client's respiratory status, the nurse should:
- Ask about chronic breathing problems
- Assess for occupation and hobby-related exposure to irritants
- Absent breath sounds may indicate pneumothorax, a serious complication after a needle biopsy or open lung biopsy
- A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency
Pulmonary Function Tests (PFTs)
- To ensure accurate PFTs, the nurse should:
- Withhold bronchodilators for 4-6 hours prior to the test
- Ensure the client did not smoke within 6-8 hours prior to the test
- Verify that the client can follow basic commands, including different breathing maneuvers
Respiratory Distress/Failure
- Wheezes are indicative of narrowed airways, and bronchodilators can help to open the air passages
- Crackles may represent a deep interstitial process, and coughing forcefully may not help the client expectorate secretions
- A barrel chest may occur as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma
Thoracentesis
- Prior to a thoracentesis, the nurse should:
- Verify that informed consent has been given by the client
- After a thoracentesis, the nurse should:
- Assess for a deviated trachea, which may indicate a tension pneumothorax
- Notify the physician immediately if a deviated trachea is detected
Communication and Documentation
- When assessing a client's health history, the nurse should:
- Maintain a nonjudgmental attitude to encourage honesty about tobacco and marijuana use
- Document the smoking history in pack-years
- The nurse should ask about allergies, including:
- The specific response to the allergen
- The treatment and response to treatment
- Documenting the allergy in a prominent place in the client's medical record
Test your knowledge on nursing care assessments related to client interactions and interventions. Includes scenarios on patient-centered care and assessment findings matched with appropriate interventions.
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