Med Surg Test bank ( Red HESI Test |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
bank Med-Surg and other resources) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
exam with correct answers |||\\\ |||\\\ |||\\\
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 - correct answer✔✔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 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 - correct answer✔✔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 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. - correct answer✔✔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 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 - correct answer✔✔A. 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 - correct answer✔✔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 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 - correct answer✔✔A. 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 - 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 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 - 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 the |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
affected area. |||\\\
9. 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. - correct answer✔✔B. Increase fluid intake to
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
3L/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-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) - correct answer✔✔C. Pneumococcal 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.
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
11. 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." -
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
correct answer✔✔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. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
bank Med-Surg and other resources) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
exam with correct answers |||\\\ |||\\\ |||\\\
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 - correct answer✔✔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 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 - correct answer✔✔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 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. - correct answer✔✔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 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 - correct answer✔✔A. 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 - correct answer✔✔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 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 - correct answer✔✔A. 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
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is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per
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minute. There is no evidence of ineffective airway clearance from the information given
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because the patient is expectorating sputum. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
7. Which of the following physical assessment findings in a patient with pneumonia best
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supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
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B. Respiratory rate of 28
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C. Presence of greenish sputum
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D. Basilar crackles - correct answer✔✔D. Basilar crackles The presence of adventitious breath
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sounds indicates that there is accumulation of secretions in the lower airways. This would be
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consistent with a nursing diagnosis of ineffective airway clearance because the patient is
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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 |||\\\
B. Fine crackles in all lobes on auscultation
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C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - correct
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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
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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 patient
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expectorate thick secretions related to pneumonia? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
A. Humidify the oxygen as able
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B. Increase fluid intake to 3L/day if tolerated.
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, C. Administer cough suppressant q4hr.
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D. Teach patient to splint the affected area. - correct answer✔✔B. Increase fluid intake to
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3L/day if tolerated. Although several interventions may help the patient expectorate mucus,
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the highest priority should be on increasing fluid intake, which will liquefy the secretions so
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that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but
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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-old patient with emphysema and pneumonia,
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which of the following vaccines should the nurse recommend the patient receive?
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A. S. aureus
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B. H. influenzae
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C. Pneumococcal
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D. Bacille Calmette-Guérin (BCG) - correct answer✔✔C. Pneumococcal The pneumococcal
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vaccine is important for patients with a history of heart or lung disease, recovering from a
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severe illness, age 65 or over, or living in a long-term care facility.
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11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has
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been most effective when the patient states which of the following measures to prevent a
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relapse? |||\\\
A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
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B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to
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reevaluate." |||\\\
C. "I will seek immediate medical treatment for any upper respiratory infections."
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D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." -
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correct answer✔✔D. "I should continue to do deep-breathing and coughing exercises for at
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least 6 weeks." It is important for the patient to continue with coughing and deep breathing
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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.
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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. |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
