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Ati Med-Surg Test Bank Latest 2024 ||Questions And Correct Answers ||With Rationales Graded A+
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Ati Med-Surg Test Bank Latest 2024 ||Questions And Correct Answers ||With Rationales Graded A+
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Ati Med-Surg Test Bank(Red Hesi TestBank Med
Surg) Latest 2023-2024
Questions And Answers
(Correct Answers) With
Rationales GradedA+
,1. The Nurse Assesses A Patient With ShortnessOf 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 answer-D.
Rationale-The Fingernail And Its Base Clubbing, A Sign Of Long-Standing Hypoxemia, Is
Evidenced By An Increase In The Angle BetweenThe 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 FollowingIs 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 answer-B.
Rationale- 5 Minutes Following Obtaining AnArterial 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 APatient Newly Admitted With Facial
Trauma, Including A Nasal Fracture. The Nurse Should:
A. Test The Drainage For The Presence OfGlucose.
B. Suction The Nose To Maintain AirwayClearance.
C. Document The Findings And ContinueMonitoring.
D. Apply A Drip Pad And Reassure The PatientThis Is Normal. - Correct answer-
A.
Rationale-Test The Drainage For The PresenceOf 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
HighestPriority Assessment Would Be:
A. Airway Patency
B. Patient Comfort
,C. Incisional Drainage
D. Blood Pressure And Heart Rate - Correct answer-A.
Rationale- Airway Patency Remember AbcsWith Prioritization. Airway Patency Is Always
The
Highest Priority And Is Essential For A PatientUndergoing Surgery Surrounding The
Upper Respiratory System.
5. When Initially Teaching A Patient The Supraglottic Swallow Following A Radical
NeckDissection, With Which Of The Following FoodsShould The Nurse Begin?
A. Cola
B. Applesauce
C. French Fries
D. White Grape Juice - Correct answer-A.Rationale- Colawhen Learning The
Supraglottic Swallow, It May Be Helpful To Start With Carbonated Beverages Because
The Effervescence Provides Clues About The Liquid'sPosition. 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 CarbonatedBeverages 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 RelatedTo Infectious Illness
B. Ineffective Thermoregulation Related ToChilling
C. Ineffective Breathing Pattern Related ToPneumonia
D. Ineffective Airway Clearance Related To Thick Secretions - Correct answer-A.
Rationale- Hyperthermia Related To InfectiousIllness 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
BecauseThe 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 answer-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 ManifestationsWould The Nurse Expect To Find
During Assessment Of A Patient Admitted With
Pneumococcal Pneumonia? A. HyperresonanceOn Percussion
B. Fine Crackles In All Lobes On Auscultation
C. Increased Vocal Fremitus On Palpation D. Vesicular Breath Sounds In All Lobes -
Correct answer-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 TheAffected Area.
9. Which Of The Following Nursing InterventionsIs 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 answer-B. Increase Fluid Intake
To3l/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-OldPatient With Emphysema And
Pneumonia, WhichOf The Following Vaccines Should The Nurse Recommend The Patient
Receive?
A. S. Aureus
B. H. Influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (Bcg) - Correct answer-C. Pneumococcal The
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