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 - correct answerD. The fingernail and its base Clubbing, a sign of longstanding hyp...
HESI Med Surg
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 - correct answerD. 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 - correct answerB. 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. - correct answerA. 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 - correct answerA. 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 - correct answerA. 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 - correct answerA. 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 - correct answerD. 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 - correct answerC.
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. - correct answerB. 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) - correct answerC. 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." - correct
answerD. "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 - correct answerD. 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" - correct answerD. 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. - correct answerC. 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 assessment
of this system. Further history taking and physical examination of other body systems can proceed once
the patient's acute respiratory distress is being managed.
15. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-
pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased
the patient's underlying respiratory defenses because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance - correct answerD. Mucociliary clearance Smoking decreases the ciliary action
in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough,
and frequent respiratory infections.
16. While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen
saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based
upon these findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. -
correct answerC. Obtain a physician's order for supplemental oxygen to be used during ambulation and
other activity. An oxygen saturation level that drops below 90% with activity indicates that the patient is
not tolerating the exercise and needs to have supplemental oxygen applied.
17. The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the
third postoperative day, the patient complains of shortness of breath, slight chest pain, and that
"something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen
saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this
episode?
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room - correct answerB. Pulmonary embolus
from deep vein thrombosis The patient presents the classic symptoms of pulmonary embolus: acute
onset of symptoms, tachypnea, shortness of breath, and chest pain.
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