UNIT 3: Assessment of Respiratory Function

Question 1

1. A client is having the tonsils removed. The client 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 1

ANS: B
Rationale: 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.

Question 2

2. The nurse is caring for a client who has just returned to the unit after a colon resection. The client is showing signs of hypoxia. The nurse knows that this is probably caused by:
   A. nitrogen narcosis.
   B. infection.
   C. impaired diffusion.
   D. shunting.

Answer 2

ANS: D

Rationale: 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.

Question 3

3. The nurse is assessing a client 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 client’s tongue and mouth.
   D. Assess the client’s nutritional status.

Answer 3

ANS: B

Rationale: 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 client’s tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.

Question 4

4. The ED nurse is assessing a client who is reporting dyspnea. The nurse auscultates the client’s chest and hears wheezing throughout the lung fields. What might this indicate about the client?
   A. Bronchoconstriction
   B. Pneumonia
   C. Hemoptysis
   D. Hemothorax

Answer 4

ANS: A
Rationale: Wheezing is a high-pitched, musical sound that is often the major finding in a client with bronchoconstriction or airway narrowing. Wheezing is not normally indicative of pneumonia (an infection of the lungs), hemoptysis (the expectoration of blood from the respiratory tract), or hemothorax (a collection of blood in the space between the chest wall and the lung).

Question 5

5. The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the client is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client’s blood?
   A. A capillary blood sample
   B. Pulse oximetry
   C. An arterial blood gas (ABG) study
   D. A complete blood count (CBC)

Answer 5

ANS: C
Rationale: 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.

Question 6

6. The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client 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 greater than or equal to 92%

Answer 6

ANS: A
Rationale: After the procedure, it is important that the client 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.

Question 7

7. A client 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
   D. Residual volume

Answer 7

ANS: C
Rationale: 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.

Question 8

8. In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client’s 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

Answer 8

ANS: D
Rationale: 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 client no discomfort. An incentive spirometer is used to assist the client with deep breathing after surgery. ABG measurement can measure SaO2, but this is an invasive procedure that can be painful. Some clients with asthma use peak flow meters to
measure levels of expired air.

Question 9

9. A client asks the nurse why an infection in the upper respiratory system is affecting the
   clarity of the client’s speech. The nurse should describe the role of what structure?
   A. Trachea
   B. Pharynx
   C. Paranasal sinuses
   D. Larynx

Answer 9

ANS: C
Rationale: 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 tube-like 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.

Question 10

10. A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position?
    A. Review images from the client’s portable chest x-ray.
    B. Turn the client to enable assessment of all lung fields.
    C. Assess the breath sounds accessible from the anterior chest wall.
    D. Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.

Answer 10

ANS: B

Rationale: Assessment of the anterior and posterior lung fields is part of the nurse’s routine evaluation. If the client is recumbent, it is essential to turn the client 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. A chest x-ray does not allow assessment of breath sounds. Assessment of only breath sounds accessible from the anterior chest wall neglects breath sounds that can only be assessed in other lung fields. All lung fields need to be assessed whether oxygen saturation is low or not.

Question 11

11. A client is undergoing testing to assess for a pleural effusion. Which of the nurse’s respiratory assessment findings would be most consistent with this diagnosis?
    A. Increased tactile fremitus, egophony, and the chest wall dull on percussion
    B. Decreased tactile fremitus, wheezing, and the chest wall hyperresonant on percussion
    C. Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
    D. Normal tactile fremitus, decreased breath sounds, and the chest wall resonant on percussion

Answer 11

ANS: C

Rationale: 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.

Question 12

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 client’s room. The nurse asks when the client produced the sputum specimen, and the client 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 client 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.

Answer 12

ANS: B

Rationale: 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.

Question 13

13. The nurse is assessing a newly admitted medical client and notes there is a depression in the lower portion of the client’s sternum. This client’s health record should note the presence of what chest deformity?
    A. A barrel chest
    B. A funnel chest
    C. A pigeon chest
    D. Kyphoscoliosis

Answer 13

ANS: B
Rationale: 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 anteroposterior diameter. Kyphoscoliosis, which is characterized by elevation of the scapula and a corresponding S-shaped spine, limits lung expansion within the thorax.

Question 14

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)

Answer 14

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

Question 15

15. A medical nurse has admitted a client to the unit with a diagnosis of failure to thrive. The client 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 client’s health care provider because these symptoms are suggestive of what issue?
    A. Pneumothorax
    B. Lung tumors
    C. Infection
    D. Pulmonary edema

Answer 15

ANS: C
Rationale: 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.

Question 16

16. A client 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

Answer 16

ANS: D
Rationale: 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.

Question 17

17. A client 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

Answer 17

ANS: D
Rationale: Vital capacity is measured by having the client 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.

Question 18

18. While assessing an acutely ill client’s 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
    B. Apnea
    C. Biot respiration
    D. Cheyne-Stokes

Answer 18

ANS: C

Rationale: The nurse will document that the client is demonstrating a Biot respiration pattern. Biot 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. Biot 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.

Question 19

19. The nurse is caring for an older client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of topical lidocaine. For what complication related to the administration of large doses of topical lidocaine in older adults should the nurse assess?
    A. Decreased urine output and hypertension
    B. Headache and vision changes
    C. Confusion and lethargy
    D. Jaundice and elevated liver enzymes

Answer 19

ANS: C
Rationale: Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy. After the procedure, the nurse will assess for confusion and lethargy in an older adult, which may be due to the large doses of lidocaine given during the procedure. The other listed signs and symptoms are not specific to this problem.

Question 20

20. While assessing a client who has pneumonia, the nurse has the client repeat the letter E while the nurse auscultates. The nurse notes that the client’s voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?
    A. Bronchophony
    B. Egophony
    C. Whispered pectoriloquy
    D. Sonorous wheezes

Answer 20

ANS: B

Rationale: This finding would be documented as egophony, which can be best assessed by instructing the client to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E. Bronchophony describes vocal resonance that is more intense and clearer than normal. Whispered pectoriloquy is a very subtle finding that is heard only in the presence of rather dense consolidation of the lungs. Sound is so enhanced by the consolidated tissue that even whispered words are heard. Sonorous wheezes are not defined as a voice sound, but rather as a breath sound.

Question 21

21. The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, “What exactly is this test for?” What would be the nurse’s best response?
    A. “A PFT measures how much air moves in and out of your lungs when you breathe.”
    B. “A PFT measures how much energy you get from the oxygen you breathe.”
    C. “A PFT measures how elastic your lungs are.”
    D. “A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.”

Answer 21

ANS: A

Rationale: PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction.
Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can
often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly

Question 22

22. A client is being treated for a pulmonary embolism, and the medical nurse is aware that the client experienced an acute disturbance in pulmonary perfusion. This involved an alteration in which aspect of normal physiology?
    A. Maintenance of constant osmotic pressure in the alveoli
    B. Maintenance of muscle tone in the diaphragm
    C. pH balance in the pulmonary veins and arteries
    D. Adequate flow of blood through the pulmonary circulation.

Answer 22

ANS: D

Rationale: Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.

Question 23

23. The nurse is performing a respiratory assessment of an adult client and is distinguishing between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. How should the nurse distinguish between these normal breath sounds?
    A. Their location over a specific area of the lung
    B. The volume of the sounds
    C. Whether they are heard on inspiration or expiration
    D. Whether or not they are continuous breath sounds

Answer 23

ANS: A
Rationale: Normal breath sounds are distinguished by their location over a specific area of the lung; they are identified as vesicular, bronchovesicular, and bronchial (tubular) breath sounds. Breath sounds are not distinguished solely on the basis of volume. Normal breath sounds are heard on both inspiration and expiration, and are continuous.

Question 24

24. A client has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
    A. Acid–base balance
    B. Perfusion
    C. Diffusion
    D. Ventilation

Answer 24

ANS: B
Rationale: Perfusion is influenced by alveolar pressure. The pulmonary capillaries are sandwiched between adjacent alveoli and, if the alveolar pressure is sufficiently high, the capillaries are squeezed. This does not constitute a disturbance in ventilation (air movement), diffusion (gas exchange), or acid–base balance.

Question 25

25. A client is scheduled to have excess pleural fluid aspirated with a needle to relieve dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe?
    A. It allows for full expansion of the lungs within the thoracic cavity.
    B. It prevents the lungs from collapsing within the thoracic cavity.
    C. It limits lung expansion within the thoracic cavity.
    D. It lubricates the movement of the thorax and lungs.

Answer 25

ANS: D

Rationale: The pleural fluid, located between two membranes known as the visceral pleura (which cover the lungs) and the parietal pleura (which line the thorax), serves to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath. The pleural fluid does not allow full expansion of the lungs, prevent the lungs from collapsing, or limit lung expansion within the thoracic cavity.

Question 26

26. The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes which type of impairment?
    A. Impaired gas exchange
    B. Collapsed bronchial structures
    C. Necrosis of the alveoli
    D. Closed bronchial tree

Answer 26

ANS: A
Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.

Question 27

27. The nurse is performing a respiratory assessment of a client who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?
    A. An appropriate perfusion–diffusion ratio
    B. An adequate ventilation–perfusion ratio
    C. Adequate diffusion of gas in shunted blood
    D. Appropriate blood nitrogen concentration

Answer 27

ANS: B
Rationale: Adequate gas exchange depends on an adequate ventilation–perfusion ratio. There is no perfusion–diffusion ratio. Adequate gas exchange does not depend on the diffusion of gas in shunted blood or a particular concentration of nitrogen.

Question 28

28. The nurse is caring for a client with lung metastases who just underwent a
    mediastinotomy. What is the nurse’s priority postprocedure care?

A. Assisting with pulmonary function testing (PFT)
B. Maintaining the client’s chest tube
C. Administering oral suction as needed
D. Performing chest physiotherapy

Answer 28

ANS: B
Rationale: Chest tube drainage is required after mediastinotomy. PFT may be needed, but it would be a lower priority than maintaining the chest tube. The client would need chest tube drainage after a mediastinotomy, not oral suctioning. Given that the client is healing from the incision made during the procedure, chest physiotherapy would be inappropriate at this time.

Question 29

29. The nurse is caring for a client who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?
    A. Sputum production
    B. Shortness of breath
    C. Throat discomfort
    D. Epistaxis

Answer 29

ANS: B
Rationale: Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis. Follow-up care in the health care facility and at home involves monitoring the client for shortness of breath (which might indicate a pneumothorax). All of the listed options are relevant assessment findings, but shortness of breath is the most serious complication.

Question 30

30. A gerontologic nurse is analyzing the data from a client’s focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiologic change?
    A. Increased diffusion of gases
    B. Decreased diffusion capacity for oxygen
    C. Decreased shunting of blood
    D. Increased ventilation

Answer 30

ANS: B
Rationale: The amount of respiratory dead space increases with age. Combined with other changes, this results in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Decreased shunting and increased ventilation do not occur with age.

Question 31

31. The nurse is assessing the respiratory status of a client who is experiencing an exacerbation of emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?
    A. Rhonchi during expiration
    B. Wheezing with discontinuous breath sounds
    C. Faint breath sounds with prolonged expiration
    D. Faint breath sounds with fine crackles

Answer 31

ANS: C
Rationale: The breath sounds of the client with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged. Fine crackles are soft, high-pitched, discontinuous popping sounds heard in mid to late inspiration that are associated with interstitial pneumonia, restrictive pulmonary disease, or bronchitis.
Wheezing is a continuous, musical, high-pitched, shrill sound associated with chronic bronchitis or bronchiectasis. Rhonchi are deep, lower-pitched rumbling sounds, with a snoring quality, that are associated with secretions or a tumor.

Question 32

32. The client has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The health care provider suspects bronchogenic carcinoma. An MRI would most likely assess for which condition in this client?
    A. Alveolar dysfunction
    B. Forced vital capacity
    C. Tidal volume
    D. Chest wall invasion

Answer 32

ANS: D
Rationale: MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma (assessment of chest wall invasion); and to evaluate inflammatory activity in interstitial lung disease, acute pulmonary embolism, and chronic thrombolytic pulmonary hypertension. Imaging would not focus on the alveoli (as would be the case in alveolar dysfunction) because the problem is in the bronchi. A static image such as MRI cannot inform pulmonary function tests.

Question 33

33. A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time would it be best for the nurse to collect the sample?
    A. Immediately after a meal
    B. First thing in the morning
    C. At bedtime
    D. After a period of exercise

Answer 33

ANS: B
Rationale: Sputum samples ideally are obtained early in the morning before the client has had anything to eat or drink

Question 34

34. The ED nurse is assessing the respiratory function of a client who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what condition?
    A. Pleurisy
    B. Emphysema
    C. Asthma
    D. Pneumonia

Answer 34

ANS: C
Rationale: Wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.

Question 35

35. The nurse is caring for a client who has been scheduled for a bronchoscopy. How should the nurse prepare the client for this procedure?
    A. Administer a bolus of IV fluids.
    B. Arrange for the insertion of a peripherally inserted central catheter.
    C. Administer nebulized bronchodilators every 2 hours until the test.
    D. Withhold food and fluids for several hours before the test.

Answer 35

ANS: D

Rationale: Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia. IV fluids, bronchodilators, and a central line are unnecessary.

Question 36

36. A client currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiologic state?
    A. The client’s tissue demands may be met, but the client will be unable to respond to physiological stressors.
    B. The client’s short-term oxygen needs will be met, but the client will be unable to expel sufficient CO2.
    C. The client will experience tissue hypoxia with no sensation of shortness of breath or labored breathing.
    D. The client will experience respiratory alkalosis with no ability to compensate.

Answer 36

ANS: A

Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiologic stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results

Question 37

37. A medical client rings the call bell and expresses alarm to the nurse, stating, “I’ve just coughed up this blood. That can’t be good, can it?” How can the nurse best determine whether the source of the blood was the client’s lungs?
    A. Obtain a sample and test the pH of the blood, if possible.
    B. Try to see if the blood is frothy or mixed with mucus.
    C. Perform oral suctioning to see if blood is obtained.
    D. Swab the back of the client’s throat to see if blood is present.

Answer 37

ANS: B

Rationale: Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum. Testing the pH of nonarterial blood samples is not common practice and would not provide important data. Similarly, oral suctioning and swabbing the client’s mouth would not reveal the source.

Question 38

38. The nurse is completing a client’s health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
    A. “Have you ever been employed in a factory, smelter, or mill?”
    B. “Does anyone in your family have any form of lung disease?”
    C. “Do you currently smoke, or have you ever smoked?”
    D. “Have you ever lived in an area that has high levels of air pollution?”

Answer 38

ANS: C
Rationale: Smoking is the single most important contributor to lung disease, exceeding the significance of environmental, occupational, and genetic factors.

Question 39

39. A client on the medical unit reports experiencing significant dyspnea, despite not having recently performed any physical activity. What assessment question should the nurse ask the client while preparing to perform a physical assessment?
    A. “On a scale from 0 to 10, how bad would you rate your shortness of breath?”
    B. “When was the last time you ate or drank anything?”
    C. “Are you feeling any nausea along with your shortness of breath?”
    D. “Do you think that some medication might help you catch your breath?”

Answer 39

ANS: A
Rationale: Gauging the severity of the client’s dyspnea is an important part of the nursing process. Oral intake and nausea are much less important considerations. The nurse must perform assessment prior to interventions such as providing medication.

Question 40

40. The nurse has assessed a client’s family history for three generations. The presence of which respiratory disease would justify this type of assessment?
    A. Asthma
    B. Obstructive sleep apnea
    C. Community-acquired pneumonia
    D. Pulmonary edema

Answer 40

ANS: A
Rationale: Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.