Examen
HESI TEST BANK MED-SURG 2024 UPDATE NEWEST ACTUAL EXAMALREADY GRADED A
- Grado
- Institución
HESI TEST BANK MED-SURG 2024 UPDATE NEWEST ACTUAL EXAMALREADY GRADED A
[Mostrar más]Vista previa 4 fuera de 76 páginas
Vista previa 4 fuera de 76 páginas
Añadir al carrito
Añadir al carrito
Vendedor
Seguir
Hosmerit
Comentarios recibidos
Vista previa del contenido
HESI TEST BANK MED-SURG 2024 UPDATE NEWESTACTUAL EXAM|ALREADY GRADED A
1.The nurse assesses a client 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 - ✅✅✅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 client 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 - ✅✅✅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.
3. The nurse notices clear nasal drainage in a client 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 client this is normal. - ✅✅✅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 client who is 3 hours postoperative laryngectomy, the nurse's highest
priority assessment would be:
A. Airway patency
B. client comfort
C. Incisional drainage
,D. Blood pressure and heart rate - ✅✅✅A. Airway patency Remember ABCs with
prioritization. Airway patency is always the highest priority and is essential for a client
undergoing surgery surrounding the upper respiratory system.
5. When initially teaching a client 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 - ✅✅✅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.
6. The nurse is caring for a client 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 - ✅✅✅A. Hyperthermia related to
infectious illness Because the client 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 client is expectorating sputum.
7. Which of the following physical assessment findings in a client 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 - ✅✅✅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 client is retaining
secretions.
8. Which of the following clinical manifestations would the nurse expect to find during
assessment of a client 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 - ✅✅✅C.
Increased vocal fremitus on palpation. A typical physical examination finding for a client 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 client
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 client to splint the affected area. - ✅✅✅B. Increase fluid intake to 3L/day if
tolerated. Although several interventions may help the client expectorate mucus, the highest
priority should be on increasing fluid intake, which will liquefy the secretions so that the client
can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the
primary intervention. Teaching the client 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 client with emphysema and pneumonia, which
of the following vaccines should the nurse recommend the client receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - ✅✅✅C. Pneumococcal The pneumococcal vaccine is
important for clients 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 client hospitalized with pneumonia has
been most effective when the client 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." -
✅✅✅D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
It is important for the client to continue with coughing and deep breathing exercises for 6 to 8
weeks until all of the infection has cleared from the lungs. A client 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 client's oxygenation saturation is below normal.
12. After admitting a client 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 client?
A. Serum laboratory studies ordered for AM
, B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - ✅✅✅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 client 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 client with unilateral malignant lung disease?
A. Positioning client on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning client with "good lung down" - ✅✅✅D. Positioning client with "good lung
down" Therapeutic positioning identifies the best position for the client assuring stable
oxygenation status. Research indicates that positioning the client with the unaffected lung
(good lung) dependent best promotes oxygenation in clients 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 client is admitted with acute respiratory distress related to cor pulmonale.
Which of the following nursing interventions is most appropriate during admission of this
client?
A. Delay any physical assessment of the client and review with the family the client's history of
respiratory problems. B. Perform a comprehensive health history with the client 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. - ✅✅✅C. Perform a physical assessment of the respiratory system and
ask specific questions related to this episode of respiratory distress.Because the client 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 client's acute respiratory distress is being managed.
15. When planning appropriate nursing interventions for a client with metastatic lung cancer
and a 60-pack-year history of cigarette smoking, the nurse recognizes that the smoking has
most likely decreased the client's underlying respiratory defenses because of impairment of
which of the following?
A. Reflex bronchoconstriction
Los beneficios de comprar resúmenes en Stuvia estan en línea:
Garantiza la calidad de los comentarios
Compradores de Stuvia evaluaron más de 700.000 resúmenes. Así estas seguro que compras los mejores documentos!
Compra fácil y rápido
Puedes pagar rápidamente y en una vez con iDeal, tarjeta de crédito o con tu crédito de Stuvia. Sin tener que hacerte miembro.
Enfócate en lo más importante
Tus compañeros escriben los resúmenes. Por eso tienes la seguridad que tienes un resumen actual y confiable. Así llegas a la conclusión rapidamente!
Preguntas frecuentes
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.
100% de satisfacción garantizada: ¿Cómo funciona?
Nuestra garantía de satisfacción le asegura que siempre encontrará un documento de estudio a tu medida. Tu rellenas un formulario y nuestro equipo de atención al cliente se encarga del resto.
Who am I buying this summary from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Hosmerit. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy this summary for $15.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
45,681 summaries were sold in the last 30 days
Founded in 2010, the go-to place to buy summaries for 14 years now