ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 20 : Assessment of Respiratory Function Questions
Question 1 of 5
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?
Correct Answer: 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 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.
Question 2 of 5
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?
Correct Answer: 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 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.
Question 3 of 5
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?
Correct Answer: B
Rationale: 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.
Question 4 of 5
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?
Correct Answer: 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 5 of 5
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 patient says the specimen is about 4 hours old. What action should the nurse take?
Correct Answer: 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.