HESI Med Surg Exam 2022, Answered-The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base
- D. The fingernail and its base Clubbing, a sign ...
the nurse assesses a patient with shortness of breath for evidence of long standing hypoxemia by inspecting a chest excursion b spinal curvatures c the respirat
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HESI Med Surg Exam 2022, Answered
The nurse assesses a patient with shortness of breath for evidence of long-standing
hypoxemia by inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base
- D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is
evidenced by an increase in the angle between the base of the nail and the fingernail to
180 degrees or more, usually accompanied by an increase in the depth, bulk, and
sponginess of the end of the finger.
2. The nurse is caring for a patient with COPD and pneumonia who has an order for
arterial blood gases to be drawn. Which of the following is the minimum length of time
the nurse should plan to hold pressure on the puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes - B. 5 minutes Following obtaining an arterial blood gas, the nurse
should hold pressure on the puncture site for 5 minutes by the clock to be sure that
bleeding has stopped. An artery is an elastic vessel under higher pressure than veins,
and significant blood loss or hematoma formation could occur if the time is
insufficient.
3. The nurse notices clear nasal drainage in a patient newly admitted with facial
trauma, including a nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.
- A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage
of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose,
which would indicate the presence of CSF.
,4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's
highest priority assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
– A. Airway patency Remember ABCs with prioritization. Airway patency is always
the highest priority and is essential for a patient undergoing surgery surrounding the
upper respiratory system.
5. When initially teaching a patient the supraglottic swallow following a radical neck
dissection, with which of the following foods should the nurse begin?
A. Cola
B. Applesauce
C. French fries
D. White grape juice
- A. ColaWhen learning the supraglottic swallow, it may be helpful to start with
carbonated beverages because the effervescence provides clues about the liquid's
position. Thin, watery fluids should be avoided because they are difficult to swallow
and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce,
would decrease the risk of aspiration, but carbonated beverages are the better choice to
start with.
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon
assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow
sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most
appropriate based upon this assessment? A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions
- A. Hyperthermia related to infectious illness Because the patient has spiked a
temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is
hyperthermia related to infectious illness. There is no evidence of a chill, and her
breathing pattern is within normal limits at 20 breaths per minute. There is no evidence
of ineffective airway clearance from the information given because the patient is
expectorating sputum.
,7. Which of the following physical assessment findings in a patient with pneumonia
best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
- D. Basilar crackles The presence of adventitious breath sounds indicates that there is
accumulation of secretions in the lower airways. This would be consistent with a
nursing diagnosis of ineffective airway clearance because the patient is retaining
secretions.
8. Which of the following clinical manifestations would the nurse expect to find during
assessment of a patient admitted with pneumococcal pneumonia? A. Hyperresonance
on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - C.
Increased vocal fremitus on palpation. A typical physical examination finding for a
patient with pneumonia is increased vocal fremitus on palpation. Other signs of
pulmonary consolidation include dullness to percussion, bronchial breath sounds, and
crackles in the affected area.
9. Which of the following nursing interventions is of the highest priority in helping a
patient expectorate thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area. - B. Increase fluid intake to 3L/day if
tolerated. Although several interventions may help the patient expectorate mucus, the
highest priority should be on increasing fluid intake, which will liquefy the secretions
so that the patient can expectorate them more easily. Humidifying the oxygen is also
helpful, but is not the primary intervention. Teaching the patient to splint the affected
area may also be helpful, but does not liquefy the secretions so that they can be
removed.
, 10. During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the patient
receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - C. Pneumococcal The pneumococcal vaccine is
important for patients with a history of heart or lung disease, recovering from a severe
illness, age 65 or over, or living in a long-term care facility.
11. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the following
measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune system
well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to
reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - D. "I should continue to do deep-breathing and coughing exercises for at
least 6 weeks." It is important for the patient to continue with coughing and deep
breathing exercises for 6 to 8 weeks until all of the infection has cleared from the
lungs. A patient should seek medical treatment for upper respiratory infections that
persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation
saturation is below normal.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the
nurse will verify that which of the following physician orders have been completed
before administering a dose of cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - D. Sputum culture and sensitivityThe nurse should
ensure that the sputum for culture and sensitivity was sent to the laboratory before
administering the cefotetan. It is important that the organisms are correctly identified
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