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TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

398

Chapter20:AssessmentofRespiratoryFunction  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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?

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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

399

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 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

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Anarterialbloodgas(ABG)study

D)

Acompletebloodcount(CBC)

Ans:

C

400

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) Ans:

Oxygensaturationof92%

A Feedback: Aftertheprocedure,itisimportantthatthepatienttakesnothingbymouthuntilthecoughreflexreturns becausethepreoperativesedationandlocalanesthesiaimpairtheprotectivelaryngealreflexand swallowingforseveralhours.Deepinspiration,adequateoxygensaturationlevels,andabsenceof nauseadonotindicatethatoralintakeissafefromtheriskofaspiration.

7.

Apatientwithchroniclungdiseaseisundergoinglungfunctiontesting.Whattestresultdenotesthe volumeofairinspiredandexpiredwithanormalbreath?

A)

Totallungcapacity

B)

Forcedvitalcapacity

C)

Tidalvolume

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

D)

Residualvolume

Ans:

C

401

Feedback: Tidalvolumereferstothevolumeofairinspiredandexpiredwithanormalbreath.Totallungcapacity isthemaximalamountofairthelungsandrespiratorypassagescanholdafteraforcedinspiration. Forcedvitalcapacityisvitalcapacityperformedwithamaximallyforcedexpiration.Residualvolumeis themaximalamountofairleftinthelungafteramaximalexpiration. 8.

Inadditiontoheartrate,bloodpressure,respiratoryrate,andtemperature,thenurseneedstoassessa patientsarterialoxygensaturation(SaO2).Whatprocedurewillbestaccomplishthis?

A)

Incentivespirometry

B)

Arterialbloodgas(ABG)measurement

C)

Peakflowmeasurement

D)

Pulseoximetry

Ans:

D Feedback: Pulseoximetryisanoninvasiveprocedureinwhichasmallsensorispositionedoverapulsating vascularbed.Itcanbeusedduringtransportandcausesthepatientnodiscomfort.Anincentive spirometerisusedtoassistthepatientwithdeepbreathingaftersurgery.ABGmeasurementcan measureSaO2,butthisisaninvasiveprocedurethatcanbepainful.Somepatientswithasthmausepeak flowmeterstomeasurelevelsofexpiredair.

9.

Apatientasksthenursewhyaninfectioninhisupperrespiratorysystemisaffectingtheclarityofhis speech.Whichstructureservesasthepatientsresonatingchamberinspeech?

A)

Trachea

B)

Pharynx

C)

Paranasalsinuses

D)

Larynx

Ans:

C

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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Feedback: Aprominentfunctionofthesinusesistoserveasaresonatingchamberinspeech.Thetrachea,also knownasthewindpipe,servesasthepassagebetweenthelarynxandthebronchi.Thepharynxisa tubelikestructurethatconnectsthenasalandoralcavitiestothelarynx.Thepharynxalsofunctionsasa passagefortherespiratoryanddigestivetracts.Themajorfunctionofthelarynxis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consciousnessisinarecumbentposition.Howshouldthenursebest assessthelungfieldsforapatientinthisposition? A)

Informthatphysicianthatthepatientisinarecumbentpositionandanticipateanorderfora portablechestx-ray.

B)

Turnthepatienttoenableassessmentofallthepatientslung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.

Ans:

B Feedback: Assessmentoftheanteriorandposteriorlungfieldsispartofthenursesroutineevaluation.Ifthepatient isrecumbent,itisessentialtoturnthepatienttoassessalllungfieldssothatdependentareascanbe assessedforbreathsounds,includingthepresenceofnormalbreathsoundsandadventitioussounds. Failuretoexaminethedependentareasofthelungscanresultinmissingsignificantfindings.This makestheothergivenoptionsunacceptable.

11. Apatientisundergoingtestingtoseeifhehasapleuraleffusion.Whichofthenursesrespiratory assessmentfindingswouldbemostconsistentwiththisdiagnosis? A)

Increasedtactilefremitus,egophony,andadullsounduponpercussionofthechestwall

B)

Decreasedtactilefremitus,wheezing,andahyperresonantsounduponpercussionofthechestwall

C)

Lungfieldsdulltopercussion,absentbreathsounds,andapleuralfrictionrub

D)

Normaltactilefremitus,decreasedbreathsounds,andaresonantsounduponpercussionofthe chestwall

Ans:

C

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

403

Feedback: Assessmentfindingsconsistentwithapleuraleffusionincludeaffectedlungfieldsbeingdullto percussionandabsenceofbreathsounds.Apleuralfrictionrubmayalsobepresent.Theotherlisted signsarenottypicallyassociatedwithapleuraleffusion. 12. Thenursedoingroundsatthebeginningofashiftnoticesasputumspecimeninacontainersittingon thebedsidetableinapatientsroom.Thenurseasksthepatientwhenheproducedthesputumspecimen andhestatesthatthespecimenisabout4hoursold.Whatactionshouldthenursetake? A)

Immediatelytakethesputumspecimentothelaboratory.

B)

Discardthespecimenandassistthepatientinobtaininganotherspecimen.

C)

Refrigeratethesputumspecimenandsubmititonceitischilled.

D)

Addasmallamountofnormalsalinetomoistenthespecimen.

Ans:

B Feedback: Sputumsamplesshouldbesubmittedtothelaboratoryassoonaspossible.Allowingthespecimento standforseveralhoursinawarmroomresultsintheovergrowthofcontaminatedorganismsandmay makeitdifficulttoidentifythepathogenicorganisms.Refrigerationofthesputumspecimenandthe additionofnormalsalinearenotappropriateactions.

13. Thenurseisassessinganewlyadmittedmedicalpatientandnotesthereisadepressioninthelower portionofthepatientssternum.Thispatientshealthrecordshouldnotethepresenceofwhatchest deformity? A)

Abarrelchest

B)

Afunnelchest

C)

Apigeonchest

D)

Kyphoscoliosis

Ans:

B Feedback: Afunnelchestoccurswhenthereisadepressioninthelowerportionofthesternum,andthismaylead tocompressionoftheheartandgreatvessels,resultinginmurmurs.Abarrelchestischaracterizedbyan increaseintheanteroposteriordiameterofthethoraxandisaresultofoverinflationofthelungs.A pigeonchestoccursasaresultofdisplacementofthesternumandincludesanincreaseinthe

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

404

anteroposteriordiameter.Kyphoscoliosis,whichischaracterizedbyelevationofthescapulaanda correspondingS-shapedspine,limitslungexpansionwithinthethorax. 14. Themedicalnursewhoworksonapulmonologyunitisawarethatseveralrespiratoryconditionscan affectlungtissuecompliance.Thepresenceofwhatconditionwouldleadtoanincreaseinlung compliance? A)

Emphysema

B)

Pulmonaryfibrosis

C)

Pleuraleffusion

D)

Acuterespiratorydistresssyndrome(ARDS)

Ans:

A Feedback: Highorincreasedcomplianceoccursifthelungshavelosttheirelasticityandthethoraxis overdistended,inconditionssuchasemphysema.Conditionsassociatedwithdecreasedcompliance includepneumothorax,hemothorax,pleuraleffusion,pulmonaryedema,atelectasis,pulmonaryfibrosis, andARDS.

15. Amedicalnursehasadmittedapatienttotheunitwithadiagnosisoffailuretothrive.Thepatienthas developedafeverandcough,soasputumspecimenhasbeenobtained.Thenursenotesthatthesputum isgreenishandthatthereisalargequantityofit.Thenursenotifiesthepatientsphysicianbecausethese symptomsaresuggestiveofwhat? A)

Pneumothorax

B)

Lungtumors

C)

Infection

D)

Pulmonaryedema

Ans:

C Feedback: Thenatureofthesputumisoftenindicativeofitscause.Aprofuseamountofpurulentsputum(thick andyellow,green,orrust-colored)orachangeincolorofthesputumisacommonsignofabacterial infection.Pink-tingedmucoidsputumsuggestsalungtumor.Profuse,frothy,pinkmaterial,often wellingupintothethroat,mayindicatepulmonaryedema.Apneumothoraxdoesnotresultincopious, greensputum.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

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16. Apatienthasbeendiagnosedwithheartfailurethathasnotyetrespondedtotreatment.Whatbreath soundshouldthenurseexpecttoassessonauscultation? A)

Expiratorywheezes

B)

Inspiratorywheezes

C)

Rhonchi

D)

Crackles

Ans:

D Feedback: Cracklesreflectunderlyinginflammationorcongestionandareoftenpresentinsuchconditionsas pneumonia,bronchitis,andcongestiveheartfailure.Rhonchiandwheezesareassociatedwithairway obstruction,whichisnotapartofthepathophysiologyofheartfailure.

17. Apatienthasadiagnosisofmultiplesclerosis.Thenurseisawarethatneuromusculardisorderssuchas multiplesclerosismayleadtoadecreasedvitalcapacity.Whatdoesvitalcapacitymeasure? A)

Thevolumeofairinhaledandexhaledwitheachbreath

B)

Thevolumeofairinthelungsafteramaximalinspiration

C)

Themaximalvolumeofairinhaledafternormalexpiration

D)

Themaximalvolumeofairexhaledfromthepointofmaximalinspiration

Ans:

D Feedback: Vitalcapacityismeasuredbyhavingthepatienttakeinamaximalbreathandexhalefullythrougha spirometer.Vitallungcapacityisthemaximalvolumeofairexhaledfromthepointofmaximal inspiration,andneuromusculardisorderssuchasmultiplesclerosismayleadtoadecreasedvital capacity.Tidalvolumeisdefinedasthevolumeofairinhaledandexhaledwitheachbreath.Thevolume ofairinthelungsafteramaximalinspirationisthetotallungcapacity.Inspiratorycapacityisthe maximalvolumeofairinhaledafternormalexpiration.

18. Whileassessinganacutelyillpatientsrespiratoryrate,thenurseassessesfournormalbreathsfollowed byanepisodeofapnealasting20seconds.Howshouldthenursedocumentthisfinding? A)

Eupnea

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

B)

Apnea

C)

Biotsrespiration

D)

Cheyne-Stokes

Ans:

C

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Feedback: ThenursewilldocumentthatthepatientisdemonstratingaBiotsrespirationpattern.Biotsrespirationis characterizedbyperiodsofnormalbreathing(threetofourbreaths)followedbyvaryingperiodsof apnea(usually10secondsto1minute).Cheyne-Stokesisasimilarrespiratorypattern,butitinvolvesa regularcyclewheretherateanddepthofbreathingincreaseandthendecreaseuntilapneaoccurs.Biots respirationisnotcharacterizedbytheincreaseanddecreaseintherateanddepth,ascharacterizedby Cheyne-Stokes.Eupneaisanormalbreathingpatternof12to18breathsperminute.Bradypneaisa slower-than-normalrate(...