HESI MED SURG 1 FINAL EXAM TEST BANK LATEST 2024
ACTUAL EXAM 350 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
inspecting:
ss
A. Chest excursion ss
B. Spinal curvatures ss
C. The respiratory pattern ss ss
D. The fingernail and its base - answer-D. The fingernail and its base Clubbing, a sign of long-
ss ss ss ss s s ff ss ss ss ss ss ss ss ss ss ss
standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
sponginess of the end of the finger.
ss ss ss ss ss ss ss
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
to be drawn. Which of the following is the minimum length of time the nurse should plan to hold
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
pressure on the puncture site?
ss ss ss ss ss
A. 2 minutes ss
B. 5 minutes
ss
C. 10 minutes ss
D. 15 minutes - answer-B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold
ss ss ff ss ss ss ss ss ss ss ss ss ss ss ss
pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
is an elastic vessel under higher pressure than veins, and significant blood loss or hematoma
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
formation could occur if the time is insufficient.
ss ss ss ss ss ss ss ss
3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nasal fracture. The nurse should:
ss ss ss ss ss
A. test the drainage for the presence of glucose.
ss ss ss ss ss ss ss
B. suctionthe nose to maintain airway clearance. s ss ss ss ss ss
C. document the findings and continue monitoring. ss ss ss ss ss
D. apply a drip pad and reassure the patient this is normal. - answer-A. test the drainage for the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
presence of glucose. Clearnasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage
ss ss ss ss ss ss ss ss ss ss ss ss ss
should be tested for the presence of glucose, which would indicate the presence of CSF.
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
,4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
assessment would be:
ss ss ss
A. Airway patency ss
B. Patient comfort ss
C. Incisional drainage ss
D. Blood pressure and heart rate - answer-A. Airway patency Remember ABCs with prioritization. Airway
ss ss ss ss ss ff ss ss ss ss ss ss ss
patency is always the highest priority and is essential for a patient undergoing surgery surrounding
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the upper respiratory system.
ss ss ss ss
5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, with
ss ss ss ss ss ss ss ss ss ss ss ss ss
which of the following foods should the nurse begin?
ss ss ss ss ss ss ss ss ss
A. Cola
B. Applesauce
C. French fries ss
D. White grape juice - answer-A. ColaWhen learning the supraglottic swallow, it may be helpful to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
start with carbonated beverages because the effervescence provides clues about the liquid's
ss ss ss ss ss ss ss ss ss ss ss ss
position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
aspiration, but carbonated beverages are the better choice to start with.
ss ss ss ss ss ss ss ss ss ss ss
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A.
ss ss ss ss s ss ss ss ss ss ss ss ss ss
Hyperthermia related to infectious illness
ss ss ss ss ss
B. Ineffective thermoregulation related to chilling
ss ss ss s ss
C. Ineffective breathing pattern related to pneumonia
ss ss ss ss ss ss
D. Ineffective airway clearance related to thick secretions - answer-A. Hyperthermia related to infectious
ss ss ss ss ss ss ss ss ff ss ss s ss
illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
ineffective airway clearance from the information given because the patient is expectorating
ss ss ss ss ss ss ss ss ss ss ss ss
sputum.
ss
,7. Which of the following physical assessment findings in a patient with pneumonia best supports the
ss ss ss ss ss ss ss ss ss ss s ss ss ss
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
ss ss ss ss ss ss ss ss ss ss ss
B. Respiratory rate of 28
ss ss ss ss
C. Presence of greenish sputum
ss ss ss ss
D. Basilar crackles - answer-D. Basilar crackles The presence of adventitious breath sounds indicates that
ss s ss ff ss ss ss ss ss ss ss ss ss ss
there is accumulation of secretions in the lower airways. This would be consistent with a nursing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
diagnosis of ineffective airway clearance because the patient is retaining secretions.
ss ss ss ss ss ss ss ss ss ss ss
8. Which of the following clinical manifestations would the nurse expect to find during assessment of a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
ss ss ss ss ss ss ss ss ss
B. Fine crackles in all lobes on auscultation
ss ss ss ss ss ss ss
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - answer-C. Increased vocal
ss ss ss s ss ss ss ss ss ss ss ss ss ss ss ss
fremitus on palpation. A typical physical examination finding for a patient with pneumonia is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to
ss ss ss ss ss ss ss ss ss ss ss ss ss
percussion, bronchial breath sounds, and crackles in the affected area.
ss ss ss ss ss ss ss ss ss ss
9. Which of the following nursing interventions is of the highest priority in helping a patient expectorate
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
thick secretions related to pneumonia?
ss ss ss ss ss
A. Humidify the oxygen as able ss ss ss ss
B. Increase fluid intake to 3L/day if tolerated. ss ss ss ss ss ss
C. Administer cough suppressant q4hr. ss ss ss
D. Teach patient to splint the affected area. - answer-B. Increase fluid intake to 3L/day if tolerated.
ss ss ss ss ss ss ss ff ss ss ss ss ss ss ss
Although several interventions may help the patient expectorate mucus, the highest priority should be
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention.
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
Teaching the patient to splint the affected area may also be helpful, but does not liquefy the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
secretions so that they can be removed.
ss ss ss ss ss ss ss
10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the
ss ss ss ss ss ss ss ss ss ss ss ss ss
following vaccines should the nurse recommend the patient receive?
ss ss ss ss ss ss ss ss ss
A. S. aureus ss
B. H. influenzae ss
C. Pneumococcal
, D. Bacille Calmette-Guérin (BCG) - answer-C. Pneumococcal The pneumococcal vaccine is important
ss ss ss ss ss ss ss ss ss ss
for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
living in a long-term care facility.
ss ss ss ss ss ss
11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been
ss ss ss ss ss ss ss ss ss ss ss ss ss
most effective when the patient states which of the following measures to prevent a relapse?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
B. "I must use home oxygen therapy for 3 months andthen will have a chest x-ray to reevaluate."
ss ss ss ss ss ss ss ss ss s ss ss ss ss ss ss ss
C. "I will seek immediate medical treatment for any upper respiratory infections."
ss ss ss ss ss ss ss ss ss ss
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." - answer-D. "I
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ff ss
should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the infection has cleared from the lungs. A patient should seek medical treatment for upper
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
required to liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
saturation is below normal.
ss ss ss ss
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
which of the following physician orders have been completed before administering a dose of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
cefotetan (Cefotan) to the patient?
ss ss ss ss ss
A. Serum laboratory studies ordered for AM
ss ss ss ss ss
B. Pulmonary function evaluation ss ss
C. Orthostatic blood pressures ss ss
D. Sputum culture and sensitivity - answer-D. Sputum culture and sensitivityThe nurse should
ss ss ss ss ss ss ss ss ss ss ss
ensure that the sputum for culture and sensitivity was sent to the laboratory before administering
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the cefotetan. It is important that the organisms are correctly identified (by the culture) before
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
their numbers are affected by the antibiotic; the test will also determine whether the proper
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be
ss ss ss ss ss ss ss ss ss ss ss ss
unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
affected by the administration of antibiotics.
ss ss ss ss ss ss
13. Which of the followingnursing interventions is most appropriate to enhance oxygenation in a
ss ss ss s ss ss s ss ss ss ss ss ss
patient with unilateral malignant lung disease?
ss ss ss ss ss ss
A. Positioning patient on right side. ss ss ss ss
B. Maintaining adequate fluid intake s s ss
ACTUAL EXAM 350 QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
inspecting:
ss
A. Chest excursion ss
B. Spinal curvatures ss
C. The respiratory pattern ss ss
D. The fingernail and its base - answer-D. The fingernail and its base Clubbing, a sign of long-
ss ss ss ss s s ff ss ss ss ss ss ss ss ss ss ss
standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
sponginess of the end of the finger.
ss ss ss ss ss ss ss
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood gases
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
to be drawn. Which of the following is the minimum length of time the nurse should plan to hold
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
pressure on the puncture site?
ss ss ss ss ss
A. 2 minutes ss
B. 5 minutes
ss
C. 10 minutes ss
D. 15 minutes - answer-B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold
ss ss ff ss ss ss ss ss ss ss ss ss ss ss ss
pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
is an elastic vessel under higher pressure than veins, and significant blood loss or hematoma
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
formation could occur if the time is insufficient.
ss ss ss ss ss ss ss ss
3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nasal fracture. The nurse should:
ss ss ss ss ss
A. test the drainage for the presence of glucose.
ss ss ss ss ss ss ss
B. suctionthe nose to maintain airway clearance. s ss ss ss ss ss
C. document the findings and continue monitoring. ss ss ss ss ss
D. apply a drip pad and reassure the patient this is normal. - answer-A. test the drainage for the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
presence of glucose. Clearnasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage
ss ss ss ss ss ss ss ss ss ss ss ss ss
should be tested for the presence of glucose, which would indicate the presence of CSF.
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
,4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
assessment would be:
ss ss ss
A. Airway patency ss
B. Patient comfort ss
C. Incisional drainage ss
D. Blood pressure and heart rate - answer-A. Airway patency Remember ABCs with prioritization. Airway
ss ss ss ss ss ff ss ss ss ss ss ss ss
patency is always the highest priority and is essential for a patient undergoing surgery surrounding
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the upper respiratory system.
ss ss ss ss
5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, with
ss ss ss ss ss ss ss ss ss ss ss ss ss
which of the following foods should the nurse begin?
ss ss ss ss ss ss ss ss ss
A. Cola
B. Applesauce
C. French fries ss
D. White grape juice - answer-A. ColaWhen learning the supraglottic swallow, it may be helpful to
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
start with carbonated beverages because the effervescence provides clues about the liquid's
ss ss ss ss ss ss ss ss ss ss ss ss
position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
aspiration, but carbonated beverages are the better choice to start with.
ss ss ss ss ss ss ss ss ss ss ss
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A.
ss ss ss ss s ss ss ss ss ss ss ss ss ss
Hyperthermia related to infectious illness
ss ss ss ss ss
B. Ineffective thermoregulation related to chilling
ss ss ss s ss
C. Ineffective breathing pattern related to pneumonia
ss ss ss ss ss ss
D. Ineffective airway clearance related to thick secretions - answer-A. Hyperthermia related to infectious
ss ss ss ss ss ss ss ss ff ss ss s ss
illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
ineffective airway clearance from the information given because the patient is expectorating
ss ss ss ss ss ss ss ss ss ss ss ss
sputum.
ss
,7. Which of the following physical assessment findings in a patient with pneumonia best supports the
ss ss ss ss ss ss ss ss ss ss s ss ss ss
nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
ss ss ss ss ss ss ss ss ss ss ss
B. Respiratory rate of 28
ss ss ss ss
C. Presence of greenish sputum
ss ss ss ss
D. Basilar crackles - answer-D. Basilar crackles The presence of adventitious breath sounds indicates that
ss s ss ff ss ss ss ss ss ss ss ss ss ss
there is accumulation of secretions in the lower airways. This would be consistent with a nursing
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
diagnosis of ineffective airway clearance because the patient is retaining secretions.
ss ss ss ss ss ss ss ss ss ss ss
8. Which of the following clinical manifestations would the nurse expect to find during assessment of a
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
ss ss ss ss ss ss ss ss ss
B. Fine crackles in all lobes on auscultation
ss ss ss ss ss ss ss
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - answer-C. Increased vocal
ss ss ss s ss ss ss ss ss ss ss ss ss ss ss ss
fremitus on palpation. A typical physical examination finding for a patient with pneumonia is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to
ss ss ss ss ss ss ss ss ss ss ss ss ss
percussion, bronchial breath sounds, and crackles in the affected area.
ss ss ss ss ss ss ss ss ss ss
9. Which of the following nursing interventions is of the highest priority in helping a patient expectorate
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
thick secretions related to pneumonia?
ss ss ss ss ss
A. Humidify the oxygen as able ss ss ss ss
B. Increase fluid intake to 3L/day if tolerated. ss ss ss ss ss ss
C. Administer cough suppressant q4hr. ss ss ss
D. Teach patient to splint the affected area. - answer-B. Increase fluid intake to 3L/day if tolerated.
ss ss ss ss ss ss ss ff ss ss ss ss ss ss ss
Although several interventions may help the patient expectorate mucus, the highest priority should be
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention.
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
Teaching the patient to splint the affected area may also be helpful, but does not liquefy the
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
secretions so that they can be removed.
ss ss ss ss ss ss ss
10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the
ss ss ss ss ss ss ss ss ss ss ss ss ss
following vaccines should the nurse recommend the patient receive?
ss ss ss ss ss ss ss ss ss
A. S. aureus ss
B. H. influenzae ss
C. Pneumococcal
, D. Bacille Calmette-Guérin (BCG) - answer-C. Pneumococcal The pneumococcal vaccine is important
ss ss ss ss ss ss ss ss ss ss
for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
living in a long-term care facility.
ss ss ss ss ss ss
11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been
ss ss ss ss ss ss ss ss ss ss ss ss ss
most effective when the patient states which of the following measures to prevent a relapse?
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
B. "I must use home oxygen therapy for 3 months andthen will have a chest x-ray to reevaluate."
ss ss ss ss ss ss ss ss ss s ss ss ss ss ss ss ss
C. "I will seek immediate medical treatment for any upper respiratory infections."
ss ss ss ss ss ss ss ss ss ss
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." - answer-D. "I
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ff ss
should continue to do deep-breathing and coughing exercises for at least 6 weeks." It is important
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the infection has cleared from the lungs. A patient should seek medical treatment for upper
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
required to liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
saturation is below normal.
ss ss ss ss
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
which of the following physician orders have been completed before administering a dose of
ss ss ss ss ss ss ss ss ss ss ss ss ss ss
cefotetan (Cefotan) to the patient?
ss ss ss ss ss
A. Serum laboratory studies ordered for AM
ss ss ss ss ss
B. Pulmonary function evaluation ss ss
C. Orthostatic blood pressures ss ss
D. Sputum culture and sensitivity - answer-D. Sputum culture and sensitivityThe nurse should
ss ss ss ss ss ss ss ss ss ss ss
ensure that the sputum for culture and sensitivity was sent to the laboratory before administering
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
the cefotetan. It is important that the organisms are correctly identified (by the culture) before
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
their numbers are affected by the antibiotic; the test will also determine whether the proper
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be
ss ss ss ss ss ss ss ss ss ss ss ss
unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be
ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss ss
affected by the administration of antibiotics.
ss ss ss ss ss ss
13. Which of the followingnursing interventions is most appropriate to enhance oxygenation in a
ss ss ss s ss ss s ss ss ss ss ss ss
patient with unilateral malignant lung disease?
ss ss ss ss ss ss
A. Positioning patient on right side. ss ss ss ss
B. Maintaining adequate fluid intake s s ss
