To assess for cranial nerve XI, we would instruct the client to:

Choice A reason: Clear bilateral lung sounds are a normal respiratory finding, indicating unobstructed airways and effective gas exchange. Abnormal sounds like wheezing or crackles would suggest pathology, but this choice reflects expected lung function, not an unexpected assessment outcome.

Choice B reason: Absence of cough is a normal finding, suggesting no airway irritation or obstruction. Coughing may indicate infection or fluid accumulation, but its absence aligns with healthy respiratory status, making this a typical and expected assessment result.

Choice C reason: Using an incentive spirometer post-surgery is an expected finding, as it promotes lung expansion and prevents atelectasis. It indicates patient compliance with respiratory therapy, a standard post-operative intervention, not an abnormal or unexpected respiratory assessment outcome.

Choice D reason: An oxygen saturation of 90% on 2 liters of oxygen via nasal cannula is unexpected, as normal saturation should be 95-100%. This suggests hypoxemia, potentially from lung pathology or inadequate oxygen delivery, warranting further investigation, making it the correct choice.

Choice A reason: The gastrointestinal tract does not provide oxygen to organs; this is the respiratory and circulatory systems’ role, delivering oxygen via lungs and blood. The GI tract focuses on digestion, absorption, and waste elimination, making this function unrelated to its physiological responsibilities.

Choice B reason: Elimination of waste is a core gastrointestinal function, achieved through defecation. The large intestine compacts waste into feces, expelling it via the rectum, a critical process for removing indigestible material and toxins, making this a valid GI tract function.

Choice C reason: Digestion of food is a primary gastrointestinal function, involving mechanical and chemical breakdown in the stomach and small intestine. Enzymes and acids process nutrients for absorption, a fundamental GI role, making this choice a correct description of its physiological tasks.

Choice D reason: Removing water-soluble waste is a gastrointestinal function, as the colon reabsorbs water, concentrating waste for elimination. This process ensures efficient waste management, distinguishing it from renal functions, making this a valid role of the GI tract in waste handling.