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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. -
ANSWER ✔✔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.
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 - ANSWER ✔✔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.
,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. - ANSWER ✔✔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.
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. - ANSWER ✔✔A
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, 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.
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) - ANSWER ✔✔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