Med Surg Test Bank (Red HESI Test Bank Med-Surg) | Answered with Rationales
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Module
Med surg
Institution
Med Surg
Med Surg Test Bank (Red HESI Test Bank Med-Surg) | Answered with Rationales 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 The fingernai...
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
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.
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
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.
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.
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.
,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
Remember ABCs with prioritization. Airway patency is always the highest priority and is
essential for a patient undergoing surgery surrounding the upper respiratory system.
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
When 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.
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
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.
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
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.
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
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.
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.
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.
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)
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.
, 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."
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.
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
The 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.
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"
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
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