Chapter 21 Assessment of Respiratory Function

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Chapter 21  Assessment of Respiratory Function

 

 

Complete Chapter Questions And Answers
 

Sample Questions

 

Multiple Choice

1. A patient is having her tonsils removed. The patient asks the nurse what function the tonsils serve. Which of the following would be the most accurate response?
A) “The tonsils aid digestion.”
B) “The tonsils help to guard the body from invasion of organisms.”

C) “The tonsils contain nerves that provoke sneezing.” D) “The tonsils regulate the airflow to the bronchi.”

Ans: B
Chapter: 21
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Teaching/Learning
Objective: 1
Page and Header: 488, Anatomic and Physiologic Overview

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, do not contain nerves that provoke sneezing, nor do they 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) Diffusion B) Interbalance C) Perfusion D) Shunting

Ans: D
Chapter: 21
Client Needs: D-1
Cognitive Level: Analysis
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Page and Header: 491, Anatomic and Physiologic Overview

Feedback: Imbalance causes shunting of blood, resulting in hypoxia (low level of cellular oxygen). Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure. Options A, B, and C are incorrect.

3. You are assessing a newly admitted patient. During the assessment, the patient demonstrates an irritated, high-pitched cough. What does the nurse suspect that the patient has?
A) Stridor
B) Laryngotracheitis

C) Bronchitis D) Pneumonia

Ans: B
Chapter: 21
Client Needs: D-4
Cognitive Level: Analysis Difficulty: Moderate
Integrated Process: Nursing Process Objective: 4
Page and Header: 496, Assessment

Feedback: Laryngotracheitis is associated with an irritated, high-pitched cough. A cough in the morning with sputum production is indicative of bronchitis. Stridor is a harsh, high-pitched sound heard on inspiration, usually without need of stethoscope, secondary to upper airway obstruction. A cough of recent onset is usually from an acute infection and may be associated

with pneumonia.

4. You are the emergency-department nurse caring for a patient complaining of dyspnea. You assess the patient’s chest and hear wheezing throughout the lung fields. What might this indicate? A) The patient is in bronchospasm.
B) The patient has pneumonia.

C) The patient needs physiotherapy. D) The patient has a hemothorax.

Ans: A
Chapter: 21
Client Needs: D-4
Cognitive Level: Analysis Difficulty: Moderate
Integrated Process: Nursing Process Objective: 3
Page and Header: 497, Assessment

Feedback: Wheezing is a high-pitched, musical sound heard mainly on expiration (asthma) or inspiration (bronchitis). It is often the major finding in a patient with bronchoconstriction or airway narrowing. Dyspnea (shortness of breath) and wheezing are generally associated with marked bronchospasm. Wheezing is not indicative of pneumonia or hemothorax. Wheezing does not indicate the need for physiotherapy.

5. You are caring for a patient admitted with chronic obstructive pulmonary disease. During your shift assessment, you find that your patient is experiencing a change in his respiratory and mental status. You are aware that the most accurate measurement of the concentration of oxygen in the patient’s blood is what?
A) A capillary blood sample
B) Pulse oximetry
C) An arterial blood gas study
D) Assessment of the patient’s nailbeds

Ans: C Chapter: 21

Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process Objective: 5
Page and Header: 508, Diagnostic Evaluation

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 it is not as accurate as an ABG. Pulse oximetry does not replace ABG measurement as it is not as accurate. Assessment of the patient’s nailbeds does not give an accurate measurement of the concentration of oxygen in the blood.

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