NSG 3800 Exam 2 – Questions With Expert
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Terms in this set (91)
A patient is having her tonsils B
removed. The patient asks the nurse Feedback: The tonsils, the adenoids, and other
what function the tonsils normally lymphoid tissue encircle the throat. These structures
serve. Which of the following would are important links in the chain of lymph nodes
be the most accurate response? guarding the body from invasion of organisms
A) The tonsils separate your windpipe entering the nose and throat. The tonsils do not aid
from your throat when you swallow. digestion, separate the trachea from the esophagus,
B) The tonsils help to guard the body or regulate airflow to the bronchi.
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.
The nurse is caring for a patient who D
has just returned to the unit after a Feedback: Shunting appears to be the main cause of
colon resection. The patient is hypoxia after thoracic or abdominal surgery and
showing signs of hypoxia. The nurse most types of respiratory failure. Impairment of
knows that this is probably caused by normal diffusion is a less common cause. Infection
what? would not likely be present at this early stage of
A) Nitrogen narcosis recovery and nitrogen narcosis only occurs from
B) Infection breathing compressed air.
C) Impaired diffusion
D) Shunting
,The nurse is assessing a patient who B
frequently coughs after eating or Feedback: Coughing after food intake may indicate
drinking. How should the nurse best aspiration of material into the tracheobronchial tree;
follow up this assessment finding? a swallowing assessment is thus indicated. Obtaining
A) Obtain a sputum sample. a sputum sample is relevant in cases of suspected
B) Perform a swallowing assessment. infection. The status of the patients tongue, mouth,
C) Inspect the patients tongue and and nutrition is not directly relevant to the problem
mouth. of aspiration.
D) Assess the patients nutritional
status.
The ED nurse is assessing a patient A
complaining of dyspnea. The nurse Feedback: Wheezing is a high-pitched, musical sound
auscultates the patients chest and that is often the major finding in a patient with
hears wheezing throughout the lung bronchoconstriction or airway narrowing. Wheezing
fields. What might this indicate? is not normally indicative of pneumonia or
A) The patient has a narrowed airway. hemothorax. Wheezing does not indicate the need
B) The patient has pneumonia. for physiotherapy.
C) The patient needs physiotherapy.
D) The patient has a hemothorax.
The nurse is caring for a patient C
admitted with an acute exacerbation Feedback: The arterial oxygen tension (partial
of chronic obstructive pulmonary pressure or PaO2) indicates the degree of
disease. During assessment, the nurse oxygenation of the blood, and the arterial carbon
finds that the patient is experiencing dioxide tension (partial pressure or PaCO2) indicates
increased dyspnea. What is the most the adequacy of alveolar
accurate measurement of the ventilation. ABG studies aid in assessing the ability of
concentration of oxygen in the the lungs to provide adequate oxygen and remove
patients blood? carbon dioxide and the ability of the kidneys to
A) A capillary blood sample reabsorb or excrete bicarbonate ions to maintain
B) Pulse oximetry normal body pH. Capillary blood samples are venous
C) An arterial blood gas (ABG) study blood, not arterial blood, so they are not as accurate
D) A complete blood count (CBC) 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.
,The nurse is caring for a patient who A
has returned to the unit following a Feedback: After the procedure, it is important that
bronchoscopy. The patient is asking the patient takes nothing by mouth until the cough
for something to drink. Which criterion reflex returns because the preoperative sedation and
will determine when the nurse should local anesthesia impair the protective laryngeal
allow the patient to drink fluids? reflex and swallowing for several hours. Deep
A)Presence of a cough and gag reflex inspiration, adequate oxygen saturation levels, and
B)Absence of nausea absence of nausea do not indicate that oral intake is
C) Ability to demonstrate deep safe from the risk of aspiration.
inspiration
D) Oxygen saturation of 92%
A patient with chronic lung disease is C
undergoing lung function testing. Feedback: Tidal volume refers to the volume of air
What test result denotes the volume inspired and expired with a normal breath. Total lung
of air inspired and expired with a capacity is the maximal amount of air the lungs and
normal breath? respiratory passages can hold after a forced
A)Total lung capacity inspiration. Forced vital capacity is vital capacity
B) Forced vital capacity performed with a maximally forced expiration.
C) Tidal volume Residual volume is the maximal amount of air left in
D) Residual volume the lung after a maximal expiration.
In addition to heart rate, blood D
pressure, respiratory rate, and Feedback: Pulse oximetry is a noninvasive procedure
temperature, the nurse needs to in which a small sensor is positioned over a pulsating
assess a patients arterial oxygen vascular bed. It can be used during transport and
saturation (SaO2). What procedure will causes the patient no discomfort. An incentive
best accomplish this? spirometer is used to assist the patient with deep
A) Incentive spirometry breathing after surgery. ABG measurement can
B) Arterial blood gas (ABG) measure SaO2, but this is an invasive procedure that
measurement can be painful. Some patients with asthma use peak
C) Peak flow measurement flow meters to measure levels of expired air.
D) Pulse oximetry
, A patient asks the nurse why an C
infection in his upper respiratory Feedback: A prominent function of the sinuses is to
system is affecting the clarity of his serve as a resonating chamber in speech. The
speech. Which structure serves as the trachea, also known as the windpipe, serves as the
patients resonating chamber in passage between the larynx and the bronchi. The
speech? pharynx is a tubelike structure that connects the
A) Trachea nasal and oral cavities to the larynx. The pharynx also
B) Pharynx functions as a passage for the respiratory and
C) Paranasal sinuses digestive tracts. The major function of the larynx is
D) Larynx vocalization through the function of the vocal cords.
The vocal cords are ligaments controlled by
muscular movements that produce sound.
10. A patient with a decreased level of B
consciousness is in a recumbent Feedback: Assessment of the anterior and posterior
position. How should the nurse best lung fields is part of the nurses routine evaluation. If
assess the lung fields for a patient in the patient is recumbent, it is essential to turn the
this position? patient to assess all lung fields so that dependent
A) Inform that physician that the areas can be assessed for breath sounds, including
patient is in a recumbent position and the presence of normal breath sounds and
anticipate an order for a portable adventitious sounds. Failure to examine the
chest x-ray. dependent areas of the lungs can result in missing
B) Turn the patient to enable significant findings. This makes the other given
assessment of all the patients lung options unacceptable.
fields.
C) Avoid turning the patient, and
assess the accessible breath sounds
from the anterior chest wall.
D) Obtain a pulse oximetry reading,
and, if the reading is low, reposition
the patient and auscultate breath
sounds.
Solutions
Save
Terms in this set (91)
A patient is having her tonsils B
removed. The patient asks the nurse Feedback: The tonsils, the adenoids, and other
what function the tonsils normally lymphoid tissue encircle the throat. These structures
serve. Which of the following would are important links in the chain of lymph nodes
be the most accurate response? guarding the body from invasion of organisms
A) The tonsils separate your windpipe entering the nose and throat. The tonsils do not aid
from your throat when you swallow. digestion, separate the trachea from the esophagus,
B) The tonsils help to guard the body or regulate airflow to the bronchi.
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.
The nurse is caring for a patient who D
has just returned to the unit after a Feedback: Shunting appears to be the main cause of
colon resection. The patient is hypoxia after thoracic or abdominal surgery and
showing signs of hypoxia. The nurse most types of respiratory failure. Impairment of
knows that this is probably caused by normal diffusion is a less common cause. Infection
what? would not likely be present at this early stage of
A) Nitrogen narcosis recovery and nitrogen narcosis only occurs from
B) Infection breathing compressed air.
C) Impaired diffusion
D) Shunting
,The nurse is assessing a patient who B
frequently coughs after eating or Feedback: Coughing after food intake may indicate
drinking. How should the nurse best aspiration of material into the tracheobronchial tree;
follow up this assessment finding? a swallowing assessment is thus indicated. Obtaining
A) Obtain a sputum sample. a sputum sample is relevant in cases of suspected
B) Perform a swallowing assessment. infection. The status of the patients tongue, mouth,
C) Inspect the patients tongue and and nutrition is not directly relevant to the problem
mouth. of aspiration.
D) Assess the patients nutritional
status.
The ED nurse is assessing a patient A
complaining of dyspnea. The nurse Feedback: Wheezing is a high-pitched, musical sound
auscultates the patients chest and that is often the major finding in a patient with
hears wheezing throughout the lung bronchoconstriction or airway narrowing. Wheezing
fields. What might this indicate? is not normally indicative of pneumonia or
A) The patient has a narrowed airway. hemothorax. Wheezing does not indicate the need
B) The patient has pneumonia. for physiotherapy.
C) The patient needs physiotherapy.
D) The patient has a hemothorax.
The nurse is caring for a patient C
admitted with an acute exacerbation Feedback: The arterial oxygen tension (partial
of chronic obstructive pulmonary pressure or PaO2) indicates the degree of
disease. During assessment, the nurse oxygenation of the blood, and the arterial carbon
finds that the patient is experiencing dioxide tension (partial pressure or PaCO2) indicates
increased dyspnea. What is the most the adequacy of alveolar
accurate measurement of the ventilation. ABG studies aid in assessing the ability of
concentration of oxygen in the the lungs to provide adequate oxygen and remove
patients blood? carbon dioxide and the ability of the kidneys to
A) A capillary blood sample reabsorb or excrete bicarbonate ions to maintain
B) Pulse oximetry normal body pH. Capillary blood samples are venous
C) An arterial blood gas (ABG) study blood, not arterial blood, so they are not as accurate
D) A complete blood count (CBC) 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.
,The nurse is caring for a patient who A
has returned to the unit following a Feedback: After the procedure, it is important that
bronchoscopy. The patient is asking the patient takes nothing by mouth until the cough
for something to drink. Which criterion reflex returns because the preoperative sedation and
will determine when the nurse should local anesthesia impair the protective laryngeal
allow the patient to drink fluids? reflex and swallowing for several hours. Deep
A)Presence of a cough and gag reflex inspiration, adequate oxygen saturation levels, and
B)Absence of nausea absence of nausea do not indicate that oral intake is
C) Ability to demonstrate deep safe from the risk of aspiration.
inspiration
D) Oxygen saturation of 92%
A patient with chronic lung disease is C
undergoing lung function testing. Feedback: Tidal volume refers to the volume of air
What test result denotes the volume inspired and expired with a normal breath. Total lung
of air inspired and expired with a capacity is the maximal amount of air the lungs and
normal breath? respiratory passages can hold after a forced
A)Total lung capacity inspiration. Forced vital capacity is vital capacity
B) Forced vital capacity performed with a maximally forced expiration.
C) Tidal volume Residual volume is the maximal amount of air left in
D) Residual volume the lung after a maximal expiration.
In addition to heart rate, blood D
pressure, respiratory rate, and Feedback: Pulse oximetry is a noninvasive procedure
temperature, the nurse needs to in which a small sensor is positioned over a pulsating
assess a patients arterial oxygen vascular bed. It can be used during transport and
saturation (SaO2). What procedure will causes the patient no discomfort. An incentive
best accomplish this? spirometer is used to assist the patient with deep
A) Incentive spirometry breathing after surgery. ABG measurement can
B) Arterial blood gas (ABG) measure SaO2, but this is an invasive procedure that
measurement can be painful. Some patients with asthma use peak
C) Peak flow measurement flow meters to measure levels of expired air.
D) Pulse oximetry
, A patient asks the nurse why an C
infection in his upper respiratory Feedback: A prominent function of the sinuses is to
system is affecting the clarity of his serve as a resonating chamber in speech. The
speech. Which structure serves as the trachea, also known as the windpipe, serves as the
patients resonating chamber in passage between the larynx and the bronchi. The
speech? pharynx is a tubelike structure that connects the
A) Trachea nasal and oral cavities to the larynx. The pharynx also
B) Pharynx functions as a passage for the respiratory and
C) Paranasal sinuses digestive tracts. The major function of the larynx is
D) Larynx vocalization through the function of the vocal cords.
The vocal cords are ligaments controlled by
muscular movements that produce sound.
10. A patient with a decreased level of B
consciousness is in a recumbent Feedback: Assessment of the anterior and posterior
position. How should the nurse best lung fields is part of the nurses routine evaluation. If
assess the lung fields for a patient in the patient is recumbent, it is essential to turn the
this position? patient to assess all lung fields so that dependent
A) Inform that physician that the areas can be assessed for breath sounds, including
patient is in a recumbent position and the presence of normal breath sounds and
anticipate an order for a portable adventitious sounds. Failure to examine the
chest x-ray. dependent areas of the lungs can result in missing
B) Turn the patient to enable significant findings. This makes the other given
assessment of all the patients lung options unacceptable.
fields.
C) Avoid turning the patient, and
assess the accessible breath sounds
from the anterior chest wall.
D) Obtain a pulse oximetry reading,
and, if the reading is low, reposition
the patient and auscultate breath
sounds.
