Nokea
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.
Correct Answer: 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 patients tongue, mouth, and nutrition is not directly relevant to the problem of aspiration.
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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
Correct Answer: D
Rationale: 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.
The nurse is completing a patients 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?
Correct Answer: C
Rationale: Smoking is the single most important contributor to lung disease, exceeding the significance of environmental, occupational, and genetic factors.
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
- D. Residual volume
Correct Answer: 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.
A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That cant be good, can it? How can the nurse best determine whether the source of the blood was the patients 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 patients throat to see if blood is present.
Correct Answer: 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 patients mouth would not reveal the source.
A patient 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
Correct Answer: 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.