Med Surg Test bank ( Red HESI Test
bank Med-Surg and other resources)
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 answers D. The fingernail and its base
Clubbing,
a sign of long-standing hypoxemia, is evidenced by an increase in the
angle
the basebetween
of the nail and the fingernail to 180 degrees or more, usually
accompanied
an increase inby 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 orderblood
arterial for gases to be drawn. Which of the following is the minimum
length
the nurseof time
should plan to hold pressure on the
puncture
A. 2 site?
minutes
B. 5
minutes
C. 10
minutes
D. 15 minutes correct answers B. 5 minutes Following obtaining an arterial
the
bloodnurse
gas,should hold pressure on the puncture site for 5 minutes by the
clockthat
sure to bebleeding has stopped. An artery is an elastic vessel under
higher
than pressure
veins, and significant blood loss or hematoma formation could occur if
the time
insufficien is
t.
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 answers
A. test thefor the presence of glucose. Clear nasal drainage suggests
drainage
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
A. Airwaybe:
B. Patient
patency
comfort
C. Incisional
drainage
,D. Blood pressure and heart rate correct answers A. Airway patency
Remember
with ABCs Airway patency is always the highest priority and is
prioritization.
essential
patient for a
undergoing surgery surrounding the upper
respiratory system.
5. When initially teaching a patient the supraglottic swallow following a
radical neckwith which of the following foods should the
dissection,
nurse begin?
A.
Cola
B.
Applesauce
C. French
fries
D. White grape juice correct answers A. ColaWhen learning the supraglottic
swallow,
may it
be helpful to start with carbonated beverages because the
effervescence
clues about theprovides
liquid's position. Thin, watery fluids should be avoided
becauseto
difficult they are and increase the risk of aspiration. Nonpourable pureed
swallow
foods,
as such
applesauce, would decrease the risk of aspiration, but carbonated
beverages
better choicearetothe 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 based
appropriate most upon this assessment? A. Hyperthermia related to
infectious
B. illness
Ineffective thermoregulation related to
chilling
C. Ineffective breathing pattern related to
pneumonia
D. Ineffective airway clearance related to thick secretions correct
answers 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
to relatedThere is no evidence of a chill, and her breathing
infectious illness.
pattern limits
normal is withinat 20 breaths per minute. There is no evidence of
ineffective
clearance from airwaythe information given because the patient is
expectorating sputum.
7. Which of the following physical assessment findings in a patient with
pneumonia
supports thebest
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 answers 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 of a patient admitted with pneumococcal pneumonia? A.
assessment
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
answers C. Increased vocal fremitus on palpation. A typical physical
examination
for finding
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
patient a
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 answers B. Increase
fluid intake
3L/day to
if tolerated. Although several interventions may help the patient
expectorate
mucus, the highest priority should be on increasing fluid intake, which will
liquefy the so that the patient can expectorate them more easily.
secretions
Humidifying
oxygen is alsothehelpful, but is not the primary intervention. Teaching the
patient
the to splint
affected area may also be helpful, but does not liquefy the secretions
so that
can be they
removed.
10. During discharge teaching for a 65-year-old patient with
emphysema which
pneumonia, and 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 answers 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
pneumonia has withbeen 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 6correct answers D. "I should continue to do deep-breathing and
weeks."
exercises for at least 6 weeks." It is important for the patient to continue
coughing
with deep
and coughing
breathing exercises for 6 to 8 weeks until all of the infection has
cleared
the from
lungs. A patient should seek medical treatment for upper respiratory
infections
persist for that
more than 7 days. Increased fluid intake, not caloric intake, is
required
liquefy to
secretions. Home O2 is not a requirement unless the patient's
oxygenation
saturation is below
normal.
12. After admitting a patient to the medical unit with a diagnosis of
pneumonia,
nurse the that which of the following physician orders have been
will verify
completed
before administering a dose of cefotetan (Cefotan) to the
patient?
, A. Serum laboratory studies ordered
forPulmonary
B. AM function
evaluation
C. Orthostatic blood
pressures
D. Sputum culture and sensitivity correct answers D. Sputum culture and
sensitivityThe
nurse should ensure that the sputum for culture and sensitivity was
sent to the before administering the cefotetan. It is important that the
laboratory
organismsidentified
correctly are (by the culture) before their numbers are affected by
antibiotic;
the test will also determine whether the proper antibiotic has been ordered
(sensitivity
testing). Although antibiotic administration should not be unduly delayed
while
for thewaiting
patient to expectorate sputum, all of the other options will not be
affected by theof
administration
antibiotics.
13. Which of the following nursing interventions is most appropriate
to enhance in a patient with unilateral malignant lung
oxygenation
disease?
A. Positioning patient on right
side.
B. Maintaining adequate fluid
intake
C. Performing postural drainage every 4
hours
D. Positioning patient with "good lung down" correct answers D. Positioning
patientlung
"good withdown" Therapeutic positioning identifies the best position for
the patient
assuring stable oxygenation status. Research indicates that positioning the
patient
the with
unaffected lung (good lung) dependent best promotes oxygenation in
patients with
unilateral lung disease. For bilateral lung disease, the right lung
down has best
ventilation and perfusion. Increasing fluid intake and performing postural
drainage airway
facilitate will clearance, but positioning is most appropriate to enhance
oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress
related to cor
pulmonale. Which of the following nursing interventions is most
appropriate
admission ofduring
this
patient?
A. Delay any physical assessment of the patient and review with the family
the patient's
history of respiratory problems. B. Perform a comprehensive health
history with
patient to review
the 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. correct answers C. Perform a physical
assessment
the respiratoryof system and ask specific questions related to this episode of
distress.Because the patient is having respiratory difficulty, the nurse
respiratory
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 patient's acute respiratory distress is being
managed.
15. When planning appropriate nursing interventions for a patient with
metastatic
cancer and lung
a 60-pack-year history of cigarette smoking, the nurse
recognizes
smoking hasthat
mostthelikely decreased the patient's underlying
respiratory
because of defenses
impairment of which of the
following?
A. Reflex
bronchoconstriction
bank Med-Surg and other resources)
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 answers D. The fingernail and its base
Clubbing,
a sign of long-standing hypoxemia, is evidenced by an increase in the
angle
the basebetween
of the nail and the fingernail to 180 degrees or more, usually
accompanied
an increase inby 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 orderblood
arterial for gases to be drawn. Which of the following is the minimum
length
the nurseof time
should plan to hold pressure on the
puncture
A. 2 site?
minutes
B. 5
minutes
C. 10
minutes
D. 15 minutes correct answers B. 5 minutes Following obtaining an arterial
the
bloodnurse
gas,should hold pressure on the puncture site for 5 minutes by the
clockthat
sure to bebleeding has stopped. An artery is an elastic vessel under
higher
than pressure
veins, and significant blood loss or hematoma formation could occur if
the time
insufficien is
t.
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 answers
A. test thefor the presence of glucose. Clear nasal drainage suggests
drainage
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
A. Airwaybe:
B. Patient
patency
comfort
C. Incisional
drainage
,D. Blood pressure and heart rate correct answers A. Airway patency
Remember
with ABCs Airway patency is always the highest priority and is
prioritization.
essential
patient for a
undergoing surgery surrounding the upper
respiratory system.
5. When initially teaching a patient the supraglottic swallow following a
radical neckwith which of the following foods should the
dissection,
nurse begin?
A.
Cola
B.
Applesauce
C. French
fries
D. White grape juice correct answers A. ColaWhen learning the supraglottic
swallow,
may it
be helpful to start with carbonated beverages because the
effervescence
clues about theprovides
liquid's position. Thin, watery fluids should be avoided
becauseto
difficult they are and increase the risk of aspiration. Nonpourable pureed
swallow
foods,
as such
applesauce, would decrease the risk of aspiration, but carbonated
beverages
better choicearetothe 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 based
appropriate most upon this assessment? A. Hyperthermia related to
infectious
B. illness
Ineffective thermoregulation related to
chilling
C. Ineffective breathing pattern related to
pneumonia
D. Ineffective airway clearance related to thick secretions correct
answers 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
to relatedThere is no evidence of a chill, and her breathing
infectious illness.
pattern limits
normal is withinat 20 breaths per minute. There is no evidence of
ineffective
clearance from airwaythe information given because the patient is
expectorating sputum.
7. Which of the following physical assessment findings in a patient with
pneumonia
supports thebest
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 answers 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 of a patient admitted with pneumococcal pneumonia? A.
assessment
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
answers C. Increased vocal fremitus on palpation. A typical physical
examination
for finding
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
patient a
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 answers B. Increase
fluid intake
3L/day to
if tolerated. Although several interventions may help the patient
expectorate
mucus, the highest priority should be on increasing fluid intake, which will
liquefy the so that the patient can expectorate them more easily.
secretions
Humidifying
oxygen is alsothehelpful, but is not the primary intervention. Teaching the
patient
the to splint
affected area may also be helpful, but does not liquefy the secretions
so that
can be they
removed.
10. During discharge teaching for a 65-year-old patient with
emphysema which
pneumonia, and 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 answers 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
pneumonia has withbeen 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 6correct answers D. "I should continue to do deep-breathing and
weeks."
exercises for at least 6 weeks." It is important for the patient to continue
coughing
with deep
and coughing
breathing exercises for 6 to 8 weeks until all of the infection has
cleared
the from
lungs. A patient should seek medical treatment for upper respiratory
infections
persist for that
more than 7 days. Increased fluid intake, not caloric intake, is
required
liquefy to
secretions. Home O2 is not a requirement unless the patient's
oxygenation
saturation is below
normal.
12. After admitting a patient to the medical unit with a diagnosis of
pneumonia,
nurse the that which of the following physician orders have been
will verify
completed
before administering a dose of cefotetan (Cefotan) to the
patient?
, A. Serum laboratory studies ordered
forPulmonary
B. AM function
evaluation
C. Orthostatic blood
pressures
D. Sputum culture and sensitivity correct answers D. Sputum culture and
sensitivityThe
nurse should ensure that the sputum for culture and sensitivity was
sent to the before administering the cefotetan. It is important that the
laboratory
organismsidentified
correctly are (by the culture) before their numbers are affected by
antibiotic;
the test will also determine whether the proper antibiotic has been ordered
(sensitivity
testing). Although antibiotic administration should not be unduly delayed
while
for thewaiting
patient to expectorate sputum, all of the other options will not be
affected by theof
administration
antibiotics.
13. Which of the following nursing interventions is most appropriate
to enhance in a patient with unilateral malignant lung
oxygenation
disease?
A. Positioning patient on right
side.
B. Maintaining adequate fluid
intake
C. Performing postural drainage every 4
hours
D. Positioning patient with "good lung down" correct answers D. Positioning
patientlung
"good withdown" Therapeutic positioning identifies the best position for
the patient
assuring stable oxygenation status. Research indicates that positioning the
patient
the with
unaffected lung (good lung) dependent best promotes oxygenation in
patients with
unilateral lung disease. For bilateral lung disease, the right lung
down has best
ventilation and perfusion. Increasing fluid intake and performing postural
drainage airway
facilitate will clearance, but positioning is most appropriate to enhance
oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress
related to cor
pulmonale. Which of the following nursing interventions is most
appropriate
admission ofduring
this
patient?
A. Delay any physical assessment of the patient and review with the family
the patient's
history of respiratory problems. B. Perform a comprehensive health
history with
patient to review
the 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. correct answers C. Perform a physical
assessment
the respiratoryof system and ask specific questions related to this episode of
distress.Because the patient is having respiratory difficulty, the nurse
respiratory
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 patient's acute respiratory distress is being
managed.
15. When planning appropriate nursing interventions for a patient with
metastatic
cancer and lung
a 60-pack-year history of cigarette smoking, the nurse
recognizes
smoking hasthat
mostthelikely decreased the patient's underlying
respiratory
because of defenses
impairment of which of the
following?
A. Reflex
bronchoconstriction
