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MED SURG TEST BANK ( RED HESI TEST BANK MED-SURG AND OTHER RESOURCES)
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MED SURG TEST BANK ( RED HESI TEST BANK MED-SURG AND OTHER RESOURCES)
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 - Answers -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 - Answers -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.
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 - Answers -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 - Answers -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 -
Answers -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. - Answers -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) - Answers -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." - Answers -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 - Answers -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" - Answers -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. - Answers -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 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.
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. - Answers -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 - Answers -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 - Answers -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.
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
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