Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
1. 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.: 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
2. 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.: 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
3. 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.: 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.
4. 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.: 4. When caring for a patient
who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
, Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
A. Airway patency
B. Patient comfort
, Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
C. Incisional drainage
D.Blood pressure and heart rate
5. 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
carbon- ated beverages are the better choice to start with.: 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
6. A. Hyperthermia related to infectious illness Because the patient has
spiked a temperature and has a diagnosis of pneumonia, the logical nursing
diagno- sis 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.: 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
7. 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.: 7. Which of the following physical
assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffec- tive airway clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D.Basilar crackles
8. C. Increased vocal fremitus on palpation. A typical physical examination
, Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
finding for a patient with pneumonia is increased vocal fremitus on palpa-
tion. Other signs of pulmonary consolidation include dullness to
percussion,
resources
1. 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.: 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
2. 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.: 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
3. 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.: 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.
4. 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.: 4. When caring for a patient
who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
, Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
A. Airway patency
B. Patient comfort
, Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
C. Incisional drainage
D.Blood pressure and heart rate
5. 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
carbon- ated beverages are the better choice to start with.: 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
6. A. Hyperthermia related to infectious illness Because the patient has
spiked a temperature and has a diagnosis of pneumonia, the logical nursing
diagno- sis 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.: 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
7. 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.: 7. Which of the following physical
assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffec- tive airway clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D.Basilar crackles
8. C. Increased vocal fremitus on palpation. A typical physical examination
, Med Surg Test bank ( Red HESI Test bank Med-Surg and other
resources
finding for a patient with pneumonia is increased vocal fremitus on palpa-
tion. Other signs of pulmonary consolidation include dullness to
percussion,
