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A patient is having her tonsils removed. The patient asks the nurse what function the tonsils
normally serve. Which of the following would be the most accurate response?
A) The tonsils separate your windpipe from your throat when you swallow.
B) The tonsils help to guard the body from invasion of organisms.
C) The tonsils make enzymes that you swallow and which aid with digestion.
D) The tonsils help with regulating the airflow down into your lungs. - Answer B
Feedback: The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These
structures are important links in the chain of lymph nodes guarding the body from invasion of
organisms entering the nose and throat. The tonsils do not aid digestion, separate the trachea
from the esophagus, or regulate airflow to the bronchi.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The
patient is showing signs of hypoxia. The nurse knows that this is probably caused by what?
A) Nitrogen narcosis
B) Infection
C) Impaired diffusion
D) Shunting - Answer D
Feedback: Shunting appears to be the main cause of hypoxia after thoracic or abdominal
surgery and most types of respiratory failure. Impairment of normal diffusion is a less common
cause. Infection would not likely be present at this early stage of recovery and nitrogen narcosis
only occurs from breathing compressed air.
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the
nurse best follow up this assessment finding?
A) Obtain a sputum sample.
B) Perform a swallowing assessment.
C) Inspect the patients tongue and mouth.
D) Assess the patients nutritional status. - Answer B
Feedback: Coughing after food intake may indicate aspiration of material into the
tracheobronchial tree; a swallowing assessment is thus indicated. Obtaining a sputum sample is
,A) The patient has a narrowed airway.
B) The patient has pneumonia.
C) The patient needs physiotherapy.
D) The patient has a hemothorax. - Answer A
Feedback: Wheezing is a high-pitched, musical sound that is often the major finding in a patient
with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of
pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive
pulmonary disease. During assessment, the nurse finds that the patient is experiencing
increased dyspnea. What is the most accurate measurement of the concentration of oxygen in
the patients blood?
A) A capillary blood sample
B) Pulse oximetry
C) An arterial blood gas (ABG) study
D) A complete blood count (CBC) - Answer C
Feedback: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of
oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2)
indicates the adequacy of alveolar
ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and
remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to
maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they
are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG
measurement, because it is not as accurate. A CBC does not indicate the concentration of
oxygen.
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The
patient is asking for something to drink. Which criterion will determine when the nurse should
allow the patient to drink fluids?
A)Presence of a cough and gag reflex
B)Absence of nausea
C) Ability to demonstrate deep inspiration
D) Oxygen saturation of 92% - Answer A
Feedback: After the procedure, it is important that the patient takes nothing by mouth until the
cough reflex returns because the preoperative sedation and local anesthesia impair the
protective laryngeal reflex and swallowing for several hours. Deep inspiration, adequate oxygen
saturation levels, and absence of nausea do not indicate that oral intake is safe from the risk of
,A)Total lung capacity
B) Forced vital capacity
C) Tidal volume
D) Residual volume - Answer C
Feedback: Tidal volume refers to the volume of air inspired and expired with a normal breath.
Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold
after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally
forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal
expiration.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to
assess a patients arterial oxygen saturation (SaO2). What procedure will best accomplish this?
A) Incentive spirometry
B) Arterial blood gas (ABG) measurement
C) Peak flow measurement
D) Pulse oximetry - Answer D
Feedback: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over
a pulsating vascular bed. It can be used during transport and causes the patient no discomfort.
An incentive spirometer is used to assist the patient with deep breathing after surgery. ABG
measurement can measure SaO2, but this is an invasive procedure that can be painful. Some
patients with asthma use peak flow meters to measure levels of expired air.
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity
of his speech. Which structure serves as the patients resonating chamber in speech?
A) Trachea
B) Pharynx
C) Paranasal sinuses
D) Larynx - Answer C
Feedback: A prominent function of the sinuses is to serve as a resonating chamber in speech.
The trachea, also known as the windpipe, serves as the passage between the larynx and the
bronchi. The pharynx is a tubelike structure that connects the nasal and oral cavities to the
larynx. The pharynx also functions as a passage for the respiratory and digestive tracts. The
major function of the larynx is vocalization through the function of the vocal cords. The vocal
cords are ligaments controlled by muscular movements that produce sound.
10. A patient with a decreased level of consciousness is in a recumbent position. How should
, C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest
wall.
D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and
auscultate breath sounds. - Answer B
Feedback: Assessment of the anterior and posterior lung fields is part of the nurses routine
evaluation. If the patient is recumbent, it is essential to turn the patient to assess all lung fields
so that dependent areas can be assessed for breath sounds, including the presence of normal
breath sounds and adventitious sounds. Failure to examine the dependent areas of the lungs
can result in missing significant findings. This makes the other given options unacceptable.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses
respiratory assessment findings would be most consistent with this diagnosis?
A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall
B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the
chest wall
C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of
the chest wall - Answer C
Feedback: Assessment findings consistent with a pleural effusion include affected lung fields
being dull to percussion and absence of breath sounds. A pleural friction rub may also be
present. The other listed signs are not typically associated with a pleural effusion.
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container
sitting on the bedside table in a patients room. The nurse asks the patient when he produced
the sputum specimen and he states that the specimen is about 4 hours old. What action should
the nurse take?
A) Immediately take the sputum specimen to the laboratory.
B) Discard the specimen and assist the patient in obtaining another specimen.
C) Refrigerate the sputum specimen and submit it once it is chilled.
D) Add a small amount of normal saline to moisten the specimen. - Answer B
feedback:Sputum samples should be submitted to the laboratory as soon as possible. Allowing
the specimen to stand for several hours in a warm room results in the overgrowth of
contaminated organisms and may make it difficult to identify the pathogenic organisms.
Refrigeration of the sputum specimen and the addition of normal saline are not appropriate
actions.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the