HESI MED SURG PROCTORED EXAM SPRING 2022
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
ANS
- D. The fingernail and its ...
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
ANS
- 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
ANS
- 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.
ANS
- 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
,ANS
- 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
ANS
- 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
ANS
- 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
ANS
- 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
ANS
- 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.
ANS
- 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)
ANS
- 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."
ANS
- 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
ANS
- 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 (by the culture) before their numbers are affected by the
antibiotic; the test will also determine whether the proper antibiotic has been ordered
(sensitivity testing). Although antibiotic administration should not be unduly delayed while
waiting for the patient to expectorate sputum, all of the other options will not be affected by
the administration of antibiotics.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation
in a patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down"
ANS
- D. Positioning patient with "good lung down" Therapeutic positioning identifies the best
position for the patient assuring stable oxygenation status. Research indicates that positioning
the patient with the unaffected lung (good lung) dependent best promotes oxygenation in
patients with unilateral lung disease. For bilateral lung disease, the right lung down has best
ventilation and perfusion. Increasing fluid intake and performing postural drainage will
facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale.
Which of the following nursing interventions is most appropriate during admission of this
patient?
A. Delay any physical assessment of the patient and review with the family the patient's
history of respiratory problems. B. Perform a comprehensive health history with the patient to
review prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific questions related
to this episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory distress on
other body functions.
ANS
- C. Perform a physical assessment of the respiratory system and ask specific questions
related to this episode of respiratory distress.Because the patient is having respiratory
difficulty, the nurse should ask specific questions about this episode and perform a physical
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