NUR 2243 NP3 Chapter 20
1. 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
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. 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. 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
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. 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.
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. 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
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. 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
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