2025 Med-Surg Exam Resource: 450
Verified Questions and Detailed Answers
(Guaranteed Accuracy, A+ Graded)
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 - ANSWERD. 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 - ANSWERB. 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 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. - ANSWERA. 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 - ANSWERA. 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 - ANSWERA. 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 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 - ANSWERA. 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 - ANSWERD. 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
Verified Questions and Detailed Answers
(Guaranteed Accuracy, A+ Graded)
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 - ANSWERD. 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 - ANSWERB. 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 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. - ANSWERA. 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 - ANSWERA. 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 - ANSWERA. 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 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 - ANSWERA. 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 - ANSWERD. 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
