CH. 17: Assessment of Respiratory Function

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?

• The tonsils separate your windpipe from your throat when you swallow.

• The tonsils help to guard the body from invasion of organisms.

• The tonsils make enzymes that you swallow and which aid with digestion.

• The tonsils help with regulating the airflow down into your lungs.

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:

• nitrogen narcosis.

• infection.

• impaired diffusion.

• shunting.

The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?

• Obtain a sputum sample.

• Perform a swallowing assessment.

• Inspect the client's tongue and mouth.

• Assess the client's nutritional status.

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?

• Bronchoconstriction

• Pneumonia

• Hemoptysis

• Hemothorax

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 capillary blood sample

• Pulse oximetry

• An arterial blood gas (ABG) study

• A complete blood count (CBC)

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?

• Presence of a cough and gag reflex

• Absence of nausea

• Ability to demonstrate deep inspiration

• Oxygen saturation of greater than or equal to 92%

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?

• Tidal volume

• Vital capacity

• Residual volume

• Total lung capacity

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?

• Incentive spirometry

• Arterial blood gas (ABG) measurement

• Peak flow measurement

• Pulse oximetry

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?

• Trachea

• Pharynx

• Paranasal sinuses

• Larynx

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?

• Review images from the client’s portable chest x-ray.

• Turn the client to enable assessment of all lung fields.
  

• Assess the breath sounds accessible from the anterior chest wall.

• Assess oxygen saturation and, if low, reposition the client and auscultate breath sounds.