Nursing440 Wk.3 (Ch.20-23), Wk.4 (Ch.51-52), Wk.5 (Ch. 44-45, 49-50, 54-55)

Nursing440 Wk.3 (Ch.20-23), Wk.4 (Ch.51-52), Wk.5 (Ch. 44-45, 49-50, 54-55)
Chapter 20: 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) 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.
Ans: B
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
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 patients tongue and mouth.
D) Assess the patients nutritional status.
Ans: B
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.
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B) The patient has pneumonia.
C) The patient needs physiotherapy.
D) The patient has a hemothorax.
Ans: A
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 patients
blood?
A) A capillary blood sample
B) Pulse oximetry
C) An arterial blood gas (ABG) study
D) A complete blood count (CBC)
Ans: C
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
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
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Ans: C
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.
8. 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
Ans: D
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.

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