NUR 2243 NP3 Chapter 20
- 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.
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 1 / 3
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 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.
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 2 / 3
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 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
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