Chapter 17 Assessment of Respiratory Function
1. 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) ìThe
tonsils separate your windpipe from your throat when you swallow.î
B) ìThe tonsils help to guard the body from invasion of organisms.î
C) ìThe tonsils make enzymes that you swallow and which aid with digestion.î
D) ìThe tonsils help with regulating the airflow down into your lungs.î
Ans: 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.
2. 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 Ans: 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.
3. 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 patient's tongue and mouth.
D) Assess the patient's nutritional status. Ans: 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 relevant in
cases of suspected infection. The status of the patient's tongue, mouth, and nutrition is not
directly relevant to the problem of aspiration.
4. The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the
patient's chest and hears wheezing throughout the lung fields. What might this indicate? A)
The patient has a narrowed airway.
B) The patient has pneumonia.
C) The patient needs physiotherapy. D) The patient has a hemothorax. Ans: 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.
5. 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 patient's blood?
A) A capillary blood sample
B) Pulse oximetry
C) An arterial blood gas (ABG) study
D) A complete blood count (CBC) Ans: 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.
6. 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% Ans: 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 aspiration.
7. A patient with chronic lung disease is undergoing lung function testing. What test result
denotes the volume of air inspired and expired with a normal breath?
A) Total lung capacity
B) Forced vital capacity
C) Tidal volume
D) Residual volume
Ans: C
Feedback:
Tidal volume refers to the volume of air inspired and expired with a normal breath.
1. 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) ìThe
tonsils separate your windpipe from your throat when you swallow.î
B) ìThe tonsils help to guard the body from invasion of organisms.î
C) ìThe tonsils make enzymes that you swallow and which aid with digestion.î
D) ìThe tonsils help with regulating the airflow down into your lungs.î
Ans: 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.
2. 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 Ans: 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.
3. 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 patient's tongue and mouth.
D) Assess the patient's nutritional status. Ans: 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 relevant in
cases of suspected infection. The status of the patient's tongue, mouth, and nutrition is not
directly relevant to the problem of aspiration.
4. The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the
patient's chest and hears wheezing throughout the lung fields. What might this indicate? A)
The patient has a narrowed airway.
B) The patient has pneumonia.
C) The patient needs physiotherapy. D) The patient has a hemothorax. Ans: 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.
5. 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 patient's blood?
A) A capillary blood sample
B) Pulse oximetry
C) An arterial blood gas (ABG) study
D) A complete blood count (CBC) Ans: 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.
6. 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% Ans: 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 aspiration.
7. A patient with chronic lung disease is undergoing lung function testing. What test result
denotes the volume of air inspired and expired with a normal breath?
A) Total lung capacity
B) Forced vital capacity
C) Tidal volume
D) Residual volume
Ans: C
Feedback:
Tidal volume refers to the volume of air inspired and expired with a normal breath.
