1. The nurse assesses a patient with shortness The fingernail and its
of breath for evidence of long-standing hypox- base
emia by inspecting: Clubbing, a sign of
A. Chest excursion long-standing hypoxemia,
B. Spinal curvatures is evidenced by an in-
C. The respiratory pattern crease in the angle be-
D. The fingernail and its base tween the base of the nail
and the fingernail to 180
degrees or more, usual-
ly accompanied by an in-
crease in the depth, bulk,
and sponginess of the end
of the finger.
2. The nurse is caring for a patient with COPD 5 minutes
and pneumonia who has an order for arterial Following obtaining an ar-
blood gases to be drawn. Which of the follow- terial blood gas, the nurse
ing is the minimum length of time the nurse should hold pressure on
should plan to hold pressure on the puncture the puncture site for 5
site? minutes by the clock to
A. 2 minutes be sure that bleeding has
B. 5 minutes stopped. An artery is an
C. 10 minutes elastic vessel under high-
D. 15 minutes er 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 A. test the drainage for the
patient newly admitted with facial trauma, in- presence of glucose.
cluding a nasal fracture. The nurse should: Clear nasal drainage sug-
A. test the drainage for the presence of glu- gests leakage of cere-
cose. brospinal fluid (CSF). The
B. suction the nose to maintain airway clear- drainage should be test-
ance. ed for the presence of glu-
C. document the findings and continue moni- cose, which would indi-
toring. cate the presence of CSF.
, HESI Med Surg
D. apply a drip pad and reassure the patient
this is normal.
4. When caring for a patient who is 3 hours post- A. Airway patency
operative laryngectomy, the nurse's highest Remember ABCs with pri-
priority assessment would be: oritization. Airway paten-
A. Airway patency cy is always the highest
B. Patient comfort priority and is essential
C. Incisional drainage for a patient undergoing
D. Blood pressure and heart rate surgery surrounding the
upper respiratory system.
5. When initially teaching a patient the supraglot- Cola
tic swallow following a radical neck dissec- When learning the supra-
tion, with which of the following foods should glottic swallow, it may be
the nurse begin? helpful to start with car-
A. Cola bonated beverages be-
B. Applesauce cause the effervescence
C. French fries provides clues about the
D. White grape juice liquid's position. Thin, wa-
tery fluids should be
avoided because they are
difficult to swallow and in-
crease the risk of aspira-
tion. Nonpourable pureed
foods, such as apple-
sauce, 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 Hyperthermia related to
the hospital with pneumonia. Upon assess- infectious illness
ment, 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?
, HESI Med Surg
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
7. Which of the following physical assessment Basilar crackles
findings in a patient with pneumonia best sup- The presence of adven-
ports the nursing diagnosis of ineffective air- titious breath sounds in-
way clearance? dicates that there is ac-
A. Oxygen saturation of 85% cumulation of secretions
B. Respiratory rate of 28 in the lower airways. This
C. Presence of greenish sputum would be consistent with
D. Basilar crackles a nursing diagnosis of in-
effective airway clearance
because the patient is re-
taining secretions.
8. Which of the following clinical manifestations C. Increased vocal fremi-
would the nurse expect to find during assess- tus on palpation.
ment of a patient admitted with pneumococcal A typical physical exam-
pneumonia? A. Hyperresonance on percus- ination finding for a pa-
sion tient with pneumonia is in-
B. Fine crackles in all lobes on auscultation creased vocal fremitus on
C. Increased vocal fremitus on palpation palpation. Other signs of
D. Vesicular breath sounds in all lobes pulmonary consolidation
include dullness to per-
cussion, bronchial breath
sounds, and crackles in
the affected area.
9. Which of the following nursing interventions Increase fluid intake to
is of the highest priority in helping a patient 3L/day if tolerated.
expectorate thick secretions related to pneu- Although several interven-
monia? tions may help the pa-
A. Humidify the oxygen as able tient expectorate mucus,
B. Increase fluid intake to 3L/day if tolerated. the highest priority should
, HESI Med Surg
C. Administer cough suppressant q4hr. be on increasing fluid in-
D. Teach patient to splint the affected area. take, which will liquefy the
secretions so that the pa-
tient can expectorate them
more easily. Humidifying
the oxygen is also help-
ful, but is not the primary
intervention. Teaching the
patient to splint the affect-
ed area may also be help-
ful, but does not liquefy
the secretions so that they
can be removed.
10. During discharge teaching for a 65-year-old Pneumococcal
patient with emphysema and pneumonia, The pneumococcal vac-
which of the following vaccines should the cine is important for pa-
nurse recommend the patient receive? tients with a history of
A. S. aureus heart or lung disease, re-
B. H. influenzae covering from a severe ill-
C. Pneumococcal ness, age 65 or over, or
D. Bacille Calmette-Guérin (BCG) living in a long-term care
facility.
11. The nurse evaluates that discharge teaching D. "I should continue to
for a patient hospitalized with pneumonia has do deep-breathing and
been most effective when the patient states coughing exercises for at
which of the following measures to prevent a least 6 weeks."
relapse? It is important for
A. "I will increase my food intake to 2400 calo- the patient to continue
ries a day to keep my immune system well." with coughing and deep
B. "I must use home oxygen therapy for 3 breathing exercises for 6
months and then will have a chest x-ray to to 8 weeks until all of the
reevaluate." infection has cleared from
C. "I will seek immediate medical treatment for the lungs. A patient should
any upper respiratory infections." seek medical treatment
D. "I should continue to do deep-breathing for upper respiratory infec-
and coughing exercises for at least 6 weeks." tions that persist for more
than 7 days. Increased flu-
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller TheAlphanurse. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $22.99. You're not tied to anything after your purchase.