Respiratory Disorders Practice Test

1. Most patients with COPD have a history of:

1. Cigarette smoking
2. Excessive alcohol consumption
3. Seasonal allergies
4. Injection drug use

2. Untreated obstructive sleep apnea may result in all of the following except:

1. Excessive daytime sleepiness

2. Sexual dysfunction
3. COPD
4. Increased risk for cardiovascular disease

3. Low birth weight is linked to increased risk of developing:

1. Seasonal allergies
2. Sinusitis
3. Childhood asthma
4. Bronchitis

4. A history of smoking, abnormal permanent enlargement of the alveoli, cough, and dyspnea suggest:

1. Asthma
2. Emphysema
3. Chronic bronchitis
4. Obstructive sleep apnea

5. All of the following are increase risk of developing lung cancer except:

1. Smoking
2. Exposure to radon or asbestos
3. Exposure to coal products or radioactive substances such as uranium
4. History of seasonal allergies

6. Which of the following statement about lymphangioleiomyomatosisis not true?

1. It is a rare lung disease that affects many more women than men
2. It involves the growth of smooth muscle cells in the lungs, pulmonary blood vessels,
lymphatics, and pleurae
3. It is of unknown etiology
4. It is considered a neoplastic disease

7. Treatment for influenza generally includes all of the following except:

 1. Ampicillin and tetracycline
2. Rest and ample fluids
3. Oseltamivir and zanamivir
4. Over-the-counter medications to relive fever, myalgias, and headache

8. Pneumonia may be caused by any of the following except:

1. Bee sting
2. Bacteria
3. Viruses
4. Mycoplasmas

9. The most common causes of pneumonia in children under age 5 are:

1. Fungi
2. Viruses
3. Bacteria
4. Mycoplasmas

10. Concern about the possibility of pandemic tuberculosis has been fueled by a rise in all of the following
except:

1. H1N1
2. The number of reported cases in the U.S.
3. MDR TB and XDR TB
4. AIDS

11. Occupational exposure to asbestos is associated with increased risk of developing:

1. AIDS
2. Mesothelioma
3. Cystic fibrosis
4. Aspiration pneumonia

12. Actions to prevent acute bronchitis may include all of the following except:

1. Frequent hand washing

2. Annual flu shot
3. Wearing a protective mask while using paint or solvents
4. Taking high doses of vitamin C

13. All of the following are true about histoplasmosis except:

1. Symptoms appear suddenly and are moderate to severe

2. It is caused by inhaling the spores of a fungus that arise from soil
3. Many cases are asymptomatic
4. Symptoms arise within 24 hours of exposure
14. Workers who handle unprocessed cotton are at risk of developing:

1. Coccidiomycosis
2. Byssinosis
3. Pertussis
4. Sarcoidosis

15. All of the following statements about pulmonary sarcoidosis are true except:

1. It causes dyspnea, dry cough, and chest pain

2. African Americans and Scandinavians are disproportionately affected
3. It is treated with antiviral agents
4. Many cases resolve without intervention

16. Cystic fibrosis patients suffer pulmonary infections of all of the following pathogens except:

1. Pseudomonas aeruginosa
2. Haemophilus influenzae
3. Staphylococcus aureus
4. Candida albicans

17. All of the following are true about acute respiratory distress syndrome (ARDS) except:

1. It generally arises in persons with serious comorbidities

2. It may be life threatening
3. It is a common complication of anesthesia
4. Some ARDS patients suffer permanent lung damage

18. Hantavirus pulmonary syndrome arises from contact with any of the following except:

1. Infected rodents
2. Infected rodent urine or droppings
3. Infected rodent saliva
4. Infected people

19. Symptoms of pertussis include all of the following except:

1. Runny nose and mild fever

2. Severe coughing
3. Choking in infants
4. Rash

20. Silicosis is a disorder characterized by all of the following except:

1. Dyspnea
2. Severe cough, tachypnea and weakness
3. Fever, night sweats and chest pain
 4. Paralysis of the lower extremities

Answers and Explanations

1. A

Approximately 80% to 90% of COPD diagnoses are attributable to cigarette smoking. About
15% of smokers display the declining pulmonary function that leads to COPD and its associated
disability. Although stopping smoking slows the progression of the disease, persons with COP
do not recover lost pulmonary function.
2. C

Although obstructive sleep apnea may exacerbate symptoms of asthma or COPD, it does not
cause these disorders. Obesity is a risk factor for sleep apnea and is related to its severity. Most
people with sleep apnea have a BMI greater than 30. Men with a neck circumference of 17
inches or greater and women with a neck circumference of 16 inches or greater are at higher risk
for sleep apnea.
3. C

Infants with birth weights of 5.5 pounds or less are at a greater risk of respiratory disorders such
as asthma than infants with normal birth weights. Risk of developing asthma also appears to be
heritable; if both parents have asthma, the risk is 50%. Maternal factors associated with increased
risk for asthma include poor maternal nutrition, smoking, and failure to breastfeed.
4. B

Emphysema is a chronic obstructive pulmonary disease (COPD). It is the fourth leading cause of
death in the United States. Symptoms of emphysema include shortness of breath, wheezing,
chronic cough, fatigue, loss of appetite, and weight loss. Smoking, exposure to secondhand
smoke, occupational exposure to fumes or dust from chemicals, grain, cotton, wood or mining
products, and HIV infection increase risk for emphysema.
5. D

In addition to the above-mentioned risk factors, environmental exposure to chemicals such as

arsenic, vinyl chloride, and mustard gas increase risk of developing lung cancer. Chronic lung
inflammation and scarring resulting from conditions such as silicosis, berylliosis, tuberculosis,
and pneumonia also may increase risk.
6. D

Lymphangioleiomyomatosis is nonmalignant proliferation of smooth muscle cells. Symptoms

include cough, dyspnea, chest pain, and hemoptysis. Because these symptoms are often present
in COPD, some cases of lymphangioleiomyomatosis are misdiagnosed. The disease is generally
diagnosed using chest x-ray and high-resolution CT; in instances where these are inconclusive,
lung biopsy may be performed.
7. A

Influenza is a viral respiratory infection that also produces body-wide symptoms, including
muscle and joint pain, headache, sore throat, nasal congestion, and fever. Most people with mild
influenza recover without drug treatment; however, those with more severe illnesses and persons
at increased risk of complications – children less than 2 years of age, pregnant women, older
adults and persons with chronic respiratory or immune disorders – may be treated with antiviral
drugs.
8. A

Pneumonia is an infection of one or both lungs. Along with the above-mentioned causes,
pneumonia may result from fungal infection, such as Pneumocystis, and in response to various
chemicals. About one-third of pneumonia cases in the United States result from respiratory
viruses. Because influenza viruses are the most common viral etiology, preventing influenza via
immunization helps to prevent pneumonia.
9. B

Children at increased risk of developing pneumonia include those born prematurely, children
who breathe secondhand smoke, children with asthma or sickle-cell disease, and children with
congenital heart defects or compromised immune systems. Children who are malnourished or in
crowded daycare settings also are at increased risk.
10. A

Multidrug-resistant tuberculosis (MDR TB) is resistant to isoniazid and rifampin. Extensively-

drug resistant tuberculosis (XDR TB) is resistant to at least isoniazid and rifampin and to any
fluoroquinolone and at least one of the three second-line injectable drugs: capreomycin,
kanamycin, or amikan. An estimated one third of the increase in TB cases worldwide can be
attributed to HIV infection, which increases susceptibility to new infection and allows activation
of latent TB.
11. B

Mesothelioma is a cancer of the lining that protects the internal organs. The pleura, which cover
the lungs and line the chest wall, are most commonly affected. Symptoms of mesothelioma
include dyspnea resulting from pleural effusion as well as chest wall pain, anemia, hemoptysis,
wheezing, hoarseness, cough, weight loss, and fatigue.
12. D

The hallmark of acute bronchitis is a persistent couch, which may be dry or productive. Other
symptoms include fever, chest pain, sore throat, wheezing, and mild dyspnea. Actions to prevent
exposure to environmental irritants such smoke, paint, paint remover, and varnish help to prevent
acute bronchitis. Persons age 60 and older may be advised to get vaccinated against
pneumococcal pneumonia.
13. A

Histoplasmosis is caused by inhaling the spores of the fungus Histoplasma capsulatum, which is
found in bird and bat excrement and in soil. Histoplasmosis is often asymptomatic; when it is
symptomatic, it is comparable to mild influenza. Chronic histoplasmosis has been compared to
tuberculosis. Although most cases resolve spontaneously, antifungal treatment is prescribed for
severe infection.
14. B

Byssinosis, also known as brown lung disease, is caused by occupational exposure to dust arising
from cotton, hemp, and flax processing. Symptoms are comparable to mild asthma and generally
resolve when exposure to the irritant ends. Using a facemask to prevent exposure to irritants
helps to prevent byssinosis.
15. C

Pulmonary sarcoidosis is an inflammatory condition that produces granulomas in the lungs.

Granulomas that persist can produce scarring of fibrotic lung tissue, which in the most severe
cases develops into pulmonary fibrosis. Chest x-ray, pulmonary function tests, blood tests,
bronchoalveolar lavage, and biopsy may be used to diagnose sarcoidosis. When treatment is
needed, it is usually a course of corticosteroids.
16. D

Bacteria grow in the mucus produced by patients with cystic fibrosis. Pseudomonas aeruginosa is
the most common bacterial source of infection in the lungs of patients with cystic fibrosis.
Azithromycin is prescribed to combat bacteria in the lungs and aerosolized antibiotics also may
be used to treat lung infections.
17. C

Acute respiratory distress syndrome (ARDS) is the sudden failure of the lungs to move sufficient
oxygen into the blood. Without adequate oxygen supply organ function may be seriously
compromised. ARDS may be caused by sepsis, trauma, pulmonary infection, blood transfusions,
smoke inhalation, narcotics, aspiration and shock. As many as 30% of cases are fatal.
18. D

Hantavirus pulmonary syndrome cannot be transmitted from person to person. The life
threatening disease comes from contact with infected rats and mice. There is no treatment or cure
for the disease, however timely oxygen therapy to assist with breathing is associated with better
clinical outcomes. Nonetheless, of the 465 cases reported in the United States through March
2007, 35% resulted in death.
19. D
Symptoms of pertussis often appear similar to cold symptoms; however, they persist and severe
coughing may result in transient loss of consciousness, vomiting, and difficulty breathing.
Treatment may involve antibiotics and intravenous fluids. Pertussis may be prevented via
immunization; the pertussis vaccine is administered in 5 doses from infancy to age 6 and
adolescents are given a booster shot between the ages of 11 and 12.
20. D

Silicosis is a lung disease that results from the inhalation of particles of silica, a mineral in sand
rock and ores. Workers in construction, mining, and sandblasting may be at risk for silicosis.
Silica dust produces inflammation, scarring, and nodular lesions in the upper lobes of the lungs.
Silicosis is irreversible. Treatment such as cough suppressants, oxygen, and bronchodilators aims
to relieve symptoms.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the
following items should the nurse keep easily accessible for the client?

A. Extra drainage system

B. Suture removal kit

C. Container of sterile water

D. Nonadherent pads
C. Container of sterile water

Rationale: The nurse should have a container of sterile water in a location that is easily
accessible for this client. The nurse should plan to place the open end of the tubing into the
sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.
A nurse in the emergency department is caring for a client who is experiencing acute respiratory
failure. Which of the following laboratory findings should the nurse expect?

A. Arterial pH 7.50

B. PaCO2 25 mmHg

C. SaO2 92%

D. PaO2 58 mm Hg
D. PaO2 58 mm Hg

Rationale: The nurse should expect the client who has acute respiratory failure to have lower
partial pressures of oxygen.
A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which
of the following findings should the nurse notify the provider?

A. Fluctuation of drainage in the tubing with inspiration

B. Continuous bubbling in the water seal chamber

C. Drainage of 75 mL in the first hour after surgery

D. Several small, dark-red blood clots in the tubing

B. Continuous bubbling in the water seal chamber

Rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires
notification of the provider. The nurse should check the system for external, correctable leaks
while she is waiting for instructions from the provider.
A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning.
Which of the following actions should the nurse take?

A. Use clean technique when suctioning the client's endotracheal tube.

B. Use a rotating motion when removing the suction catheter.

C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube.

D. Suction the client's endotracheal tube every 2 hr.

B. Use a rotating motion when removing the suction catheter.

Rationale: The nurse should rotate the suction catheter during withdrawal to reduce the risk of
tissue trauma.
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the
client in which of the following positions to promote effective breathing?

A. Lateral position with a pillow at the back and over the chest to support the arm

B. High-Fowler's position with the arms supported on the over-bed table

C. Semi-Fowler's position with pillows supporting both arms

D. Supine position with the head of the bed elevated to 15°

B. High-Fowler's position with the arms supported on the over-bed table

Rationale: The nurse should place the client in a position that allows for greater expansion of the
chest, such as sitting upright and leaning slightly forward while supporting both arms with
pillows for comfort on the over-bed table.
A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary
to general anesthesia effects and incisional pain. Which of the following ABG values indicates
the client is experiencing respiratory acidosis?

A. pH 7.50, PO2 95 mm Hg, PaCO2 25 mmHg, HCO3- 22 mEq/L

B. pH 7.50, PO2 87 mm Hg, PaCO2 35 mmHg, HCO3- 30 mEq/L

C. pH 7.30, PO2 90 mm Hg, PaCO2 35 mmHg, HCO3- 20 mEq/L

D. pH 7.30, PO2 80 mmHg, PaCO2 55 mmHg, HCO3- 22 mEq/L

D. pH 7.30, PO2 80 mmHg, PaCO2 55 mmHg, HCO3- 22 mEq/L

Rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the
PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow
delivery devices should the nurse use to provide the client with the highest level of oxygen?

A. Nasal cannula

B. Nonrebreather mask

C. Simple face mask

D. Partial rebreather mask

B. Nonrebreather mask

Rationale: The nurse should use a non-rebreather mask for a client in respiratory distress to
provide the highest oxygen level. A non-rebreather mask is made up of a reservoir bag from
which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the
reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This
device delivers greater than 90% FiO2.
A nurse is admitting a client who has active tuberculosis. Which of the following isolation
precautions should the nurse implement?

A. Airborne

B. Neutropenic

C. Contact

D. Droplet
A. Airborne

Rationale: The nurse should initiate airborne precautions for the client who has tuberculosis
because tuberculosis is a respiratory infection that is spread through the air. The client should be
placed in a room with negative airflow pressure filtered through a high-efficiency particulate air
(HEPA) filter. Members of the healthcare team should not enter the client's room without
wearing an N95 respirator mask.
A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of
the following findings is the priority for the nurse to report to the provider?

A. Bleeding at the surgical site

B. Decreased oxygen saturation

C. Urinary retention

D. Increased pain level

B. Decreased oxygen saturation

Rationale: Using the airway, breathing, circulation approach to client care, the nurse should
identify decreased oxygen saturation as the priority finding to address and report to the provider.
A client who is postoperative following a total laryngectomy is at higher risk for hypoxia due to
airway obstruction.
A nurse is creating a plan of care for a client who has COPD. Which of the following
interventions should the nurse include?

A. Schedule respiratory treatments following meals.

B. Have the client sit up in a chair for 2-hr periods three times per day.

C. Provide a diet that is high in calories and protein.

D. Combine activities to allow for longer rest periods between activities.

C. Provide a diet that is high in calories and protein.

Rationale: The nurse should provide the client who has COPD with a diet that is high in calories
and protein and low in carbohydrates.
A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical
manifestations should the nurse expect?

A. Decreased fremitus

B. SaO2 95% on room air

C. Temperature 38.8° C (101.8° F)

D. Bradypnea
C. Temperature 38.8° C (101.8° F)
Rationale: An elevated temperature is an expected finding for a client who has bacterial
pneumonia.
A nurse working in the emergency department is caring for a client following an acute chest
trauma. Which of the following findings indicates to the nurse the client is possibly experiencing
a tension pneumothorax?

A. Collapsed neck veins on the affected side

B. Collapsed neck veins on the unaffected side

C. Tracheal deviation to the affected side

D. Tracheal deviation to the unaffected side

D. Tracheal deviation to the unaffected side

Rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a
possible indicator the client is experiencing a tension pneumothorax. A tension pneumothorax
results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea
to deviate to the unaffected side.
A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary
embolism?

A. A client who is 48 hr postoperative following a total hip arthroplasty

B. A client who is 8 hr postoperative following an open surgical appendectomy

C. A client who is 2 hr postoperative following an open reduction external fixation of the right
radius

D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A. A client who is 48 hr postoperative following a total hip arthroplasty

Rationale: The nurse should identify that the client who has undergone a total hip replacement
surgery is at greatest risk for a pulmonary embolus due to decreased mobility of the affected
extremity and an increased amount of blood clots form in the veins of the thigh following hip
surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty. The nurse should
intervene to reduce the risk by applying sequential compression devises or antiembolic stockings
and by administering anticoagulant medications.
A nurse is caring for a client who has asthma and is receiving albuterol. For which of the
following adverse effects should the nurse monitor the client?

A. Hyperkalemia
B. Dyspnea

C. Tachycardia

D. Candidiasis
C. Tachycardia

The nurse should monitor the client for tachycardia, which is a common adverse effect of this
medication, especially if the client uses albuterol on a regular basis.
A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of
the following statements by the client indicates an understanding of the teaching?

A. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around
my stoma."

B. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb
drainage."

C. "I should remove the old twill ties after the new ties are in place."

D. "I should apply suction while inserting the catheter into my tracheostomy tube."
C. "I should remove the old twill ties after the new ties are in place."

Rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in
place to remove the old ties. This practice can prevent accidental decannulation.
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate
sedation. The nurse should place the priority on which of the following assessments?

A. Presence of gag reflex

B. Pain level rating using a 0-10 scale

C. Hydration status

D. Appearance of the IV insertion site

A. Presence of gag reflex

Rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore,
the priority assessment by the nurse is to determine the return of the gag reflex.
A nurse is providing teaching to a client who has chronic asthma and a new prescription for
montelukast. Which of the following client statements indicates an understanding of the
teaching?

A. "I will monitor my heart rate every day while taking this medication."
B. "I will make sure I have this medication with me at all times."

C. "I will need to carefully rinse my mouth after I take this medication."

D. "I will take this medication every night even if I don't have symptoms."
D. "I will take this medication every night even if I don't have symptoms."

Rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily
basis in the evening.
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new
prescription for rifampin. Which of the following instructions should the nurse include?

A. "Ringing in the ears is an adverse effect of this medication."

B. "Have your skin test repeated in 4 months to show a positive result."

C. "Expect your urine and other secretions to be orange while taking this medication."

D. "Remember to take this medication with a sip of water just before your first bite of each
meal."
C. "Expect your urine and other secretions to be orange while taking this medication."

Rationale: The nurse should inform the client that rifampin will turn urine and other secretions
orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider
if manifestations of hepatitis occur including jaundice, fatigue or malaise.
A nurse in the emergency department is caring for a client who is experiencing a pulmonary
embolism. Which of the following actions should the nurse take first?

A. Apply supplemental oxygen.

B. Increase the rate of IV fluids.

C. Administer pain medication.

D. Initiate cardiac monitoring.

A. Apply supplemental oxygen.

Rationale: When using the airway, breathing, circulation approach to client care, the greatest risk
to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply
supplemental oxygen.
A nurse is assisting the provider who is performing a thoracentesis at the bedside of a client.
Which of the following actions should the nurse take? (Select all that apply.)
A. Wear goggles and mask during the procedure.

B. Cleanse the procedure area with an antiseptic solution.

C. Instruct the client to take deep breaths during the procedure.

D. Position the client laterally on the affected side before the procedure.

E. Apply pressure to the site after the procedure.

A. Wear goggles and mask during the procedure.

B. Cleanse the procedure area with an antiseptic solution.

E. Apply pressure to the site after the procedure.

Rationale:
Wear goggles and mask during the procedure is correct. The nurse and provider should wear
goggles and a mask to reduce the risk of exposure to pleural fluid.

Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution
decreases the risk of infection, which is increased due to the invasive nature of the procedure.

Apply pressure to the site after the procedure is correct. The application of pressure decreases the
risk of bleeding at the procedure site.
A nurse is planning care for a client who has asthma. Which of the following medications should
the nurse plan to administer during an acute asthma attack?

A. Cromolyn sodium

B. Prednisone

C. Fluticasone/salmeterol

D. Albuterol
D. Albuterol

Rationale: The nurse should administer albuterol because it acts quickly to produce
bronchodilation during an acute asthma attack.
A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on
four clients. For which of the following clients should the nurse clarify the provider's
prescription?

A. A client who has epistaxis

B. A client who has amyotrophic lateral sclerosis

C. A client who has pneumonia

D. A client who has emphysema

A. A client who has epistaxis

Rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has
nasal bleeding because this intervention might cause an increase in bleeding.
A nurse is caring for a client who is receiving mechanical ventilation when the low pressure
alarm sounds. Which of the following situations should the nurse recognize as a possible cause
of the alarm?

A. Excess secretions

B. Kinks in the tubing

C. Artificial airway cuff leak

D. Biting on the endotracheal tube

C. Artificial airway cuff leak

Rationale: An artificial airway cuff leak interferes with oxygenation and causes the low pressure
alarm to sound.
A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation.
Which of the following assessments is the best method for the nurse to use to determine the
effectiveness of the current treatment regimen?

A. Blood pressure

B. Capillary refill

C. Arterial blood gases

D. Heart rate
C. Arterial blood gases

Rationale: When using the airway, breathing, circulation approach to client care, the nurse
should place priority on evaluating arterial blood gases to determine serum oxygen saturation
and acid-base balance.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the
following findings should the nurse report to the provider?

A. Decreased bowel sounds

B. Oxygen saturation 92%

C. CO2 24 mEq/L
D. Intercostal retractions
D. Intercostal retractions

Rationale: The nurse should report intercostal retractions to the provider because this finding
indicates increasing respiratory compromise in a client who has ARDS.
A nurse is caring for a client who has a pulmonary embolism. Which of the following
interventions is the priority?

A. Provide a quiet environment.

B. Encourage use of incentive spirometry every 1 to 2 hr.

C. Obtain a blood sample for electrolyte study.

D. Administer heparin via continuous IV infusion.

D. Administer heparin via continuous IV infusion.

Rationale: Using the airway, breathing, circulation approach to client care, the nurse should place
priority on stabilizing circulation to the lungs by administering heparin to prevent further clot
formation. Therefore, this is the priority intervention.
A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the
following is the priority assessment finding?

A. Pallor

B. Insertion site pain

C. Persistent cough

D. Temperature 37.3° C (99.1° F)

C. Persistent cough

Rationale: When using the airway, breathing, circulation approach to client care, the nurse
determines that the priority finding is persistent cough because this indicates a tension
pneumothorax, which is a medical emergency.
A nurse is assessing a client who has emphysema. Which of the following findings should the
nurse report to the provider?

A. Rhonchi on inspiration

B. Elevated temperature

C. Barrel-shaped chest

D. Diminished breath sounds

B. Elevated temperature

Rationale: The nurse should report an elevated temperature to the provider because it can
indicate a possible respiratory infection. Clients who have emphysema are at risk for the
development of pneumonia and other respiratory infections.

A nurse in a provider's office is assessing a client who has COPD. Which of the following
findings is the priority for the nurse to report to the provider.

A. Increased anterior-posterior chest diameter

B. Productive cough with green sputum

C. Clubbing of the fingers

D. Pursed-lip breathing with exertion

B. Productive cough with green sputum

Rationale: When using the urgent vs non-urgent approach to client care, the nurse should
determine that the priority finding is a productive cough with green sputum. The nurse should
report this finding to the provider because it can indicate infection.
A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations
should the nurse expect?

A. Blood-tinged sputum

B. Decreased tactile fremitus

C. Resonance with percussion

D. Peripheral edema
A. Blood-tinged sputum

Rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.