Med Surg Test bank ( Red HESI Test bank Med-Surg and other resource
1. The nurse assesses a patient with D. The fingernail and its base Club-
shortness of breath for evidence bing, a sign of long-standing hypox-
of long-standing hypoxemia by in- emia, is evidenced by an increase in
specting: the angle between the base of the nail
A. Chest excursion and the fingernail to 180 degrees or
B. Spinal curvatures more, usually accompanied by an in-
C. The respiratory pattern crease in the depth, bulk, and spongi-
D. The fingernail and its base ness of the end of the finger.
2. 2. The nurse is caring for a pa- B. 5 minutes Following obtaining an
tient with COPD and pneumonia arterial blood gas, the nurse should
who has an order for arterial blood hold pressure on the puncture site for
gases to be drawn. Which of the 5 minutes by the clock to be sure that
following is the minimum length of bleeding has stopped. An artery is an
time the nurse should plan to hold elastic vessel under higher pressure
pressure on the puncture site? than veins, and significant blood loss
A. 2 minutes or hematoma formation could occur if
B. 5 minutes the time is insufficient.
C. 10 minutes
D. 15 minutes
3. 3. The nurse notices clear nasal A. test the drainage for the presence
drainage in a patient newly admit- of glucose. Clear nasal drainage sug-
ted with facial trauma, including a gests leakage of cerebrospinal fluid
nasal fracture. The nurse should: (CSF). The drainage should be test-
A. test the drainage for the pres- ed for the presence of glucose, which
ence of glucose. would indicate the presence of CSF.
B. suction the nose to maintain air-
way clearance.
C. document the findings and con-
tinue monitoring.
D. apply a drip pad and reassure the
patient this is normal.
4. 4. When caring for a patient who A. Airway patency Remember ABCs
is 3 hours postoperative laryngec- with prioritization. Airway patency is
tomy, the nurse's highest priority always the highest priority and is
assessment would be: essential for a patient undergoing
A. Airway patency
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B. Patient comfort surgery surrounding the upper respi-
C. Incisional drainage ratory system.
D. Blood pressure and heart rate
5. 5. When initially teaching a pa- A. ColaWhen learning the supraglottic
tient the supraglottic swallow fol- swallow, it may be helpful to start with
lowing a radical neck dissection, carbonated beverages because the
with which of the following foods effervescence provides clues about
should the nurse begin? the liquid's position. Thin, watery flu-
A. Cola ids should be avoided because they
B. Applesauce are difficult to swallow and increase
C. French fries the risk of aspiration. Nonpourable
D. White grape juice pureed foods, such as applesauce,
would decrease the risk of aspiration,
but carbonated beverages are the bet-
ter choice to start with.
6. 6. The nurse is caring for a pa- A. Hyperthermia related to infectious
tient admitted to the hospital with illness Because the patient has spiked
pneumonia. Upon assessment, the a temperature and has a diagnosis
nurse notes a temperature of 101.4° of pneumonia, the logical nursing di-
F, a productive cough with yellow agnosis is hyperthermia related to in-
sputum and a respiratory rate of fectious illness. There is no evidence
20. Which of the following nurs- of a chill, and her breathing pattern
ing diagnosis is most appropriate is within normal limits at 20 breaths
based upon this assessment? A. per minute. There is no evidence of
Hyperthermia related to infectious ineffective airway clearance from the
illness information given because the patient
B. Ineffective thermoregulation re- is expectorating sputum.
lated to chilling
C. Ineffective breathing pattern re-
lated to pneumonia
D. Ineffective airway clearance re-
lated to thick secretions
7. 7. Which of the following physical D. Basilar crackles The presence of
assessment findings in a patient adventitious breath sounds indicates
with pneumonia best supports the that there is accumulation of secre-
nursing diagnosis of ineffective air- tions in the lower airways. This would
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way clearance? A. Oxygen satura- be consistent with a nursing diagno-
tion of 85% sis of ineffective airway clearance be-
B. Respiratory rate of 28 cause the patient is retaining secre-
C. Presence of greenish sputum tions.
D. Basilar crackles
8. 8. Which of the following clinical C. Increased vocal fremitus on pal-
manifestations would the nurse ex- pation. A typical physical examination
pect to find during assessment of finding for a patient with pneumonia is
a patient admitted with pneumo- increased vocal fremitus on palpation.
coccal pneumonia? A. Hyperreso- Other signs of pulmonary consolida-
nance on percussion tion include dullness to percussion,
B. Fine crackles in all lobes on aus- bronchial breath sounds, and crackles
cultation in the affected area.
C. Increased vocal fremitus on pal-
pation D. Vesicular breath sounds
in all lobes
9. 9. Which of the following nursing B. Increase fluid intake to 3L/day if
interventions is of the highest pri- tolerated. Although several interven-
ority in helping a patient expec- tions may help the patient expectorate
torate thick secretions related to mucus, the highest priority should be
pneumonia? on increasing fluid intake, which will
A. Humidify the oxygen as able liquefy the secretions so that the pa-
B. Increase fluid intake to 3L/day if tient can expectorate them more easi-
tolerated. ly. Humidifying the oxygen is also help-
C. Administer cough suppressant ful, but is not the primary intervention.
q4hr. Teaching the patient to splint the af-
D. Teach patient to splint the affect- fected area may also be helpful, but
ed area. does not liquefy the secretions so that
they can be removed.
10. 10. During discharge teaching for C. Pneumococcal The pneumococcal
a 65-year-old patient with emphy- vaccine is important for patients with
sema and pneumonia, which of a history of heart or lung disease, re-
the following vaccines should the covering from a severe illness, age 65
nurse recommend the patient re- or over, or living in a long-term care
ceive? facility.
A. S. aureus
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B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. 11. The nurse evaluates that dis- D. "I should continue to do
charge teaching for a patient hos- deep-breathing and coughing exercis-
pitalized with pneumonia has been es for at least 6 weeks." It is important
most effective when the patient for the patient to continue with cough-
states which of the following mea- ing and deep breathing exercises for
sures to prevent a relapse? 6 to 8 weeks until all of the infection
A. "I will increase my food intake has cleared from the lungs. A patient
to 2400 calories a day to keep my should seek medical treatment for up-
immune system well." per respiratory infections that persist
B. "I must use home oxygen thera- for more than 7 days. Increased fluid
py for 3 months and then will have intake, not caloric intake, is required to
a chest x-ray to reevaluate." liquefy secretions. Home O2 is not a
C. "I will seek immediate medical requirement unless the patient's oxy-
treatment for any upper respiratory genation saturation is below normal.
infections."
D. "I should continue to do
deep-breathing and coughing exer-
cises for at least 6 weeks."
12. 12. After admitting a patient to the D. Sputum culture and sensitivityThe
medical unit with a diagnosis of nurse should ensure that the sputum
pneumonia, the nurse will verify for culture and sensitivity was sent
that which of the following physi- to the laboratory before administering
cian orders have been completed the cefotetan. It is important that the
before administering a dose of ce- organisms are correctly identified (by
fotetan (Cefotan) to the patient? the culture) before their numbers are
A. Serum laboratory studies or- affected by the antibiotic; the test will
dered for AM also determine whether the proper an-
B. Pulmonary function evaluation tibiotic has been ordered (sensitivity
C. Orthostatic blood pressures testing). Although antibiotic adminis-
D. Sputum culture and sensitivity tration should not be unduly delayed
while waiting for the patient to expec-
torate sputum, all of the other options
will not be affected by the administra-
tion of antibiotics.
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