NSG 3800 - EXAM 2
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) 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.
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
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 dittusion 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 drink-
ing. 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 relevant in cases of suspected infection. The status of the patients
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 patients 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.
Answer A
Feedback
Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchocon- striction 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 patients blood?
A) A capillary blood sample
B) Pulse oximetry
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) 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.
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
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 dittusion 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 drink-
ing. 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 relevant in cases of suspected infection. The status of the patients
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 patients 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.
Answer A
Feedback
Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchocon- striction 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 patients blood?
A) A capillary blood sample
B) Pulse oximetry
