HESI MED SURG EXAM NEWEST 2024 200 QUESTIONS AND CORREC
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
Study online at https://quizlet.com/_fvcv7a
The nurse assesses a patient with shortness of breath for evi-
D. The fingernail and its base Clubbing, a sign of long-standing
dence of long-standing hypoxemia by inspecting:
hypoxemia, is evidenced by an increase in the angle between the
A. Chest excursion
base of the nail and the fingernail to 180 degrees or more, usually
B. Spinal curvatures
accompanied by an increase in the depth, bulk, and sponginess
C. The respiratory pattern
of the end of the finger.
D. The fingernail and its base
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
B. 5 minutes Following obtaining an arterial blood gas, the nurse
the following is the minimum length of time the nurse should plan
should hold pressure on the puncture site for 5 minutes by the
to hold pressure on the puncture site?
clock to be sure that bleeding has stopped. An artery is an elastic
A. 2 minutes
vessel under higher pressure than veins, and significant blood loss
B. 5 minutes
or hematoma formation could occur if the time is insufficient.
C. 10 minutes
D. 15 minutes
3. The nurse notices clear nasal drainage in a patient newly
admitted with facial trauma, including a nasal fracture. The nurse
A. test the drainage for the presence of glucose. Clear nasal
should:
drainage suggests leakage of cerebrospinal fluid (CSF). The
A. test the drainage for the presence of glucose.
drainage should be tested for the presence of glucose, which
B. suction the nose to maintain airway clearance.
would indicate the presence of CSF.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.
4. When caring for a patient who is 3 hours postoperative laryn-
gectomy, the nurse's highest priority assessment would be:
A. Airway patency Remember ABCs with prioritization. Airway
A. Airway patency
patency is always the highest priority and is essential for a patient
B. Patient comfort
undergoing surgery surrounding the upper respiratory system.
C. Incisional drainage
D. Blood pressure and heart rate
5. When initially teaching a patient the supraglottic swallow fol- A. ColaWhen learning the supraglottic swallow, it may be helpful to
lowing a radical neck dissection, with which of the following foods start with carbonated beverages because the effervescence pro-
should the nurse begin? vides clues about the liquid's position. Thin, watery fluids should
A. Cola be avoided because they are difficult to swallow and increase the
B. Applesauce risk of aspiration. Nonpourable pureed foods, such as applesauce,
C. French fries would decrease the risk of aspiration, but carbonated beverages
D. White grape juice 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 A. Hyperthermia related to infectious illness Because the patient
101.4° F, a productive cough with yellow sputum and a respiratory has spiked a temperature and has a diagnosis of pneumonia,
rate of 20. Which of the following nursing diagnosis is most ap- the logical nursing diagnosis is hyperthermia related to infectious
propriate based upon this assessment? A. Hyperthermia related illness. There is no evidence of a chill, and her breathing pattern is
to infectious illness within normal limits at 20 breaths per minute. There is no evidence
B. Ineffective thermoregulation related to chilling of ineffective airway clearance from the information given because
C. Ineffective breathing pattern related to pneumonia the patient is expectorating sputum.
D. Ineffective airway clearance related to thick secretions
7. Which of the following physical assessment findings in a patient
D. Basilar crackles The presence of adventitious breath sounds
with pneumonia best supports the nursing diagnosis of ineffective
indicates that there is accumulation of secretions in the lower
airway clearance? A. Oxygen saturation of 85%
airways. This would be consistent with a nursing diagnosis of
B. Respiratory rate of 28
ineffective airway clearance because the patient is retaining se-
C. Presence of greenish sputum
cretions.
D. Basilar crackles
8. Which of the following clinical manifestations would the nurse
C. Increased vocal fremitus on palpation. A typical physical ex-
expect to find during assessment of a patient admitted with pneu-
amination finding for a patient with pneumonia is increased vocal
mococcal pneumonia? A. Hyperresonance on percussion
fremitus on palpation. Other signs of pulmonary consolidation
B. Fine crackles in all lobes on auscultation
include dullness to percussion, bronchial breath sounds, and
C. Increased vocal fremitus on palpation D. Vesicular breath
crackles in the affected area.
sounds in all lobes
9. Which of the following nursing interventions is of the highest B. Increase fluid intake to 3L/day if tolerated. Although several
priority in helping a patient expectorate thick secretions related to interventions may help the patient expectorate mucus, the highest
pneumonia? priority should be on increasing fluid intake, which will liquefy the
, HESI MED SURG EXAM NEWEST 2024 200 QUESTIONS AND CORREC
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
Study online at https://quizlet.com/_fvcv7a
secretions so that the patient can expectorate them more easily.
A. Humidify the oxygen as able
Humidifying the oxygen is also helpful, but is not the primary
B. Increase fluid intake to 3L/day if tolerated.
intervention. Teaching the patient to splint the affected area may
C. Administer cough suppressant q4hr.
also be helpful, but does not liquefy the secretions so that they
D. Teach patient to splint the affected area.
can be removed.
10. During discharge teaching for a 65-year-old patient with em-
physema and pneumonia, which of the following vaccines should
the nurse recommend the patient receive? C. Pneumococcal The pneumococcal vaccine is important for
A. S. aureus patients with a history of heart or lung disease, recovering from a
B. H. influenzae severe illness, age 65 or over, or living in a long-term care facility.
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. The nurse evaluates that discharge teaching for a patient hos-
pitalized with pneumonia has been most effective when the patient
D. "I should continue to do deep-breathing and coughing exercises
states which of the following measures to prevent a relapse?
for at least 6 weeks." It is important for the patient to continue
A. "I will increase my food intake to 2400 calories a day to keep
with coughing and deep breathing exercises for 6 to 8 weeks until
my immune system well."
all of the infection has cleared from the lungs. A patient should
B. "I must use home oxygen therapy for 3 months and then will
seek medical treatment for upper respiratory infections that persist
have a chest x-ray to reevaluate."
for more than 7 days. Increased fluid intake, not caloric intake,
C. "I will seek immediate medical treatment for any upper respi-
is required to liquefy secretions. Home O2 is not a requirement
ratory infections."
unless the patient's oxygenation saturation is below normal.
D. "I should continue to do deep-breathing and coughing exercises
for at least 6 weeks."
D. Sputum culture and sensitivityThe nurse should ensure that the
12. After admitting a patient to the medical unit with a diagnosis
sputum for culture and sensitivity was sent to the laboratory before
of pneumonia, the nurse will verify that which of the following
administering the cefotetan. It is important that the organisms are
physician orders have been completed before administering a
correctly identified (by the culture) before their numbers are affect-
dose of cefotetan (Cefotan) to the patient?
ed by the antibiotic; the test will also determine whether the proper
A. Serum laboratory studies ordered for AM
antibiotic has been ordered (sensitivity testing). Although antibiotic
B. Pulmonary function evaluation
administration should not be unduly delayed while waiting for the
C. Orthostatic blood pressures
patient to expectorate sputum, all of the other options will not be
D. Sputum culture and sensitivity
affected by the administration of antibiotics.
D. Positioning patient with "good lung down" Therapeutic posi-
13. Which of the following nursing interventions is most appropri- tioning identifies the best position for the patient assuring stable
ate to enhance oxygenation in a patient with unilateral malignant oxygenation status. Research indicates that positioning the patient
lung disease? with the unaffected lung (good lung) dependent best promotes
A. Positioning patient on right side. oxygenation in patients with unilateral lung disease. For bilateral
B. Maintaining adequate fluid intake lung disease, the right lung down has best ventilation and perfu-
C. Performing postural drainage every 4 hours sion. Increasing fluid intake and performing postural drainage will
D. Positioning patient with "good lung down" facilitate airway clearance, but positioning is most appropriate to
enhance oxygenation.
14. A 71-year-old patient is admitted with acute respiratory dis-
tress related to cor pulmonale. Which of the following nursing
interventions is most appropriate during admission of this patient?
C. Perform a physical assessment of the respiratory system and
A. Delay any physical assessment of the patient and review with
ask specific questions related to this episode of respiratory dis-
the family the patient's history of respiratory problems. B. Perform
tress.Because the patient is having respiratory difficulty, the nurse
a comprehensive health history with the patient to review prior
should ask specific questions about this episode and perform a
respiratory problems.
physical assessment of this system. Further history taking and
C. Perform a physical assessment of the respiratory system and
physical examination of other body systems can proceed once the
ask specific questions related to this episode of respiratory dis-
patient's acute respiratory distress is being managed.
tress.
D. Complete a full physical examination to determine the effect of
the respiratory distress on other body functions.
15. When planning appropriate nursing interventions for a patient
with metastatic lung cancer and a 60-pack-year history of ciga-
D. Mucociliary clearance Smoking decreases the ciliary action
rette smoking, the nurse recognizes that the smoking has most
in the tracheobronchial tree, resulting in impaired clearance of
likely decreased the patient's underlying respiratory defenses be-
respiratory secretions, chronic cough, and frequent respiratory
cause of impairment of which of the following?
infections.
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
, HESI MED SURG EXAM NEWEST 2024 200 QUESTIONS AND CORREC
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
Study online at https://quizlet.com/_fvcv7a
C. Cough reflex
D. Mucociliary clearance
16. While ambulating a patient with metastatic lung cancer, the
nurse observes a drop in oxygen saturation from 93% to 86%.
Which of the following nursing interventions is most appropriate
based upon these findings?
C. Obtain a physician's order for supplemental oxygen to be used
A. Continue with ambulation as this is a normal response to
during ambulation and other activity. An oxygen saturation level
activity.
that drops below 90% with activity indicates that the patient is not
B. Move the oximetry probe from the finger to the earlobe for more
tolerating the exercise and needs to have supplemental oxygen
accurate monitoring during activity.
applied.
C. Obtain a physician's order for supplemental oxygen to be used
during ambulation and other activity.
D. Obtain a physician's order for arterial blood gas determinations
to verify the oxygen saturation.
17. The nurse is caring for a 73-year-old patient who underwent
a left total knee arthroplasty. On the third postoperative day, the
patient complains of shortness of breath, slight chest pain, and
that "something is wrong." Temperature is 98.4o F, blood pressure
130/88, respirations 36, and oxygen saturation 91% on room B. Pulmonary embolus from deep vein thrombosis The patient
air. Which of the following should the nurse first suspect as the presents the classic symptoms of pulmonary embolus: acute on-
etiology of this episode? set of symptoms, tachypnea, shortness of breath, and chest pain.
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room
18. In the case of pulmonary embolus from deep vein thrombosis,
D. Sit the patient up in bed as tolerated and apply oxygen.The
which of the following actions should the nurse take first?
patient's clinical picture is consistent with pulmonary embolus, and
A. Notify the physician.
the first action the nurse takes should be to assist the patient. For
B. Administer a nitroglycerin tablet sublingually.
this reason, the nurse should sit the patient up as tolerated and
C. Conduct a thorough assessment of the chest pain.
apply oxygen before notifying the physician.
D. Sit the patient up in bed as tolerated and apply oxygen.
19. The nurse is caring for a postoperative patient with sudden
onset of respiratory distress. The physician orders a STAT venti-
lation-perfusion scan. Which of the following explanations should
A. This test involves injection of a radioisotope to outline the
the nurse provide to the patient about the procedure?
blood vessels in the lungs, followed by inhalation of a radioisotope
A. This test involves injection of a radioisotope to outline the blood
gas.A ventilation-perfusion scan has two parts. In the perfusion
vessels in the lungs, followed by inhalation of a radioisotope gas.
portion, a radioisotope is injected into the blood and the pulmonary
B. This test will use special technology to examine cross sections
vasculature is outlined. In the ventilation part, the patient inhales
of the chest with use of a contrast dye.
a radioactive gas that outlines the alveoli.
C. This test will use magnetic fields to produce images of the lungs
and chest. D. This test involves injecting contrast dye into a blood
vessel to outline the blood vessels of the lungs.
20. During assessment of a 45-year-old patient with asthma, the
nurse notes wheezing and dyspnea. The nurse interprets that C. Narrowing of the airwayNarrowing of the airway leads to re-
these symptoms are related to which of the following pathophysi- duced airflow, making it difficult for the patient to breathe and
ologic changes? A. Laryngospasm B. Overdistention of the alveoli producing the characteristic wheezing.
C. Narrowing of the airway D. Pulmonary edema
21. A 45-year-old man with asthma is brought to the emergency
department by automobile. He is short of breath and appears
frightened. During the initial nursing assessment, which of the
A. Anxiety An early symptom during an asthma attack is anxiety
following clinical manifestations might be present as an early
because he is acutely aware of the inability to get sufficient air to
symptom during an exacerbation of asthma?
breathe. He will be hypoxic early on with decreased PaCO2 and
A. Anxiety
increased pH as he is hyperventilating.
B. Cyanosis
C. Hypercapnia
D. Bradycardia
22. The nurse is assigned to care for a patient who has anxiety and
an exacerbation of asthma. Which of the following is the primary
reason for the nurse to carefully inspect the chest wall of this
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
Study online at https://quizlet.com/_fvcv7a
The nurse assesses a patient with shortness of breath for evi-
D. The fingernail and its base Clubbing, a sign of long-standing
dence of long-standing hypoxemia by inspecting:
hypoxemia, is evidenced by an increase in the angle between the
A. Chest excursion
base of the nail and the fingernail to 180 degrees or more, usually
B. Spinal curvatures
accompanied by an increase in the depth, bulk, and sponginess
C. The respiratory pattern
of the end of the finger.
D. The fingernail and its base
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
B. 5 minutes Following obtaining an arterial blood gas, the nurse
the following is the minimum length of time the nurse should plan
should hold pressure on the puncture site for 5 minutes by the
to hold pressure on the puncture site?
clock to be sure that bleeding has stopped. An artery is an elastic
A. 2 minutes
vessel under higher pressure than veins, and significant blood loss
B. 5 minutes
or hematoma formation could occur if the time is insufficient.
C. 10 minutes
D. 15 minutes
3. The nurse notices clear nasal drainage in a patient newly
admitted with facial trauma, including a nasal fracture. The nurse
A. test the drainage for the presence of glucose. Clear nasal
should:
drainage suggests leakage of cerebrospinal fluid (CSF). The
A. test the drainage for the presence of glucose.
drainage should be tested for the presence of glucose, which
B. suction the nose to maintain airway clearance.
would indicate the presence of CSF.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.
4. When caring for a patient who is 3 hours postoperative laryn-
gectomy, the nurse's highest priority assessment would be:
A. Airway patency Remember ABCs with prioritization. Airway
A. Airway patency
patency is always the highest priority and is essential for a patient
B. Patient comfort
undergoing surgery surrounding the upper respiratory system.
C. Incisional drainage
D. Blood pressure and heart rate
5. When initially teaching a patient the supraglottic swallow fol- A. ColaWhen learning the supraglottic swallow, it may be helpful to
lowing a radical neck dissection, with which of the following foods start with carbonated beverages because the effervescence pro-
should the nurse begin? vides clues about the liquid's position. Thin, watery fluids should
A. Cola be avoided because they are difficult to swallow and increase the
B. Applesauce risk of aspiration. Nonpourable pureed foods, such as applesauce,
C. French fries would decrease the risk of aspiration, but carbonated beverages
D. White grape juice 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 A. Hyperthermia related to infectious illness Because the patient
101.4° F, a productive cough with yellow sputum and a respiratory has spiked a temperature and has a diagnosis of pneumonia,
rate of 20. Which of the following nursing diagnosis is most ap- the logical nursing diagnosis is hyperthermia related to infectious
propriate based upon this assessment? A. Hyperthermia related illness. There is no evidence of a chill, and her breathing pattern is
to infectious illness within normal limits at 20 breaths per minute. There is no evidence
B. Ineffective thermoregulation related to chilling of ineffective airway clearance from the information given because
C. Ineffective breathing pattern related to pneumonia the patient is expectorating sputum.
D. Ineffective airway clearance related to thick secretions
7. Which of the following physical assessment findings in a patient
D. Basilar crackles The presence of adventitious breath sounds
with pneumonia best supports the nursing diagnosis of ineffective
indicates that there is accumulation of secretions in the lower
airway clearance? A. Oxygen saturation of 85%
airways. This would be consistent with a nursing diagnosis of
B. Respiratory rate of 28
ineffective airway clearance because the patient is retaining se-
C. Presence of greenish sputum
cretions.
D. Basilar crackles
8. Which of the following clinical manifestations would the nurse
C. Increased vocal fremitus on palpation. A typical physical ex-
expect to find during assessment of a patient admitted with pneu-
amination finding for a patient with pneumonia is increased vocal
mococcal pneumonia? A. Hyperresonance on percussion
fremitus on palpation. Other signs of pulmonary consolidation
B. Fine crackles in all lobes on auscultation
include dullness to percussion, bronchial breath sounds, and
C. Increased vocal fremitus on palpation D. Vesicular breath
crackles in the affected area.
sounds in all lobes
9. Which of the following nursing interventions is of the highest B. Increase fluid intake to 3L/day if tolerated. Although several
priority in helping a patient expectorate thick secretions related to interventions may help the patient expectorate mucus, the highest
pneumonia? priority should be on increasing fluid intake, which will liquefy the
, HESI MED SURG EXAM NEWEST 2024 200 QUESTIONS AND CORREC
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
Study online at https://quizlet.com/_fvcv7a
secretions so that the patient can expectorate them more easily.
A. Humidify the oxygen as able
Humidifying the oxygen is also helpful, but is not the primary
B. Increase fluid intake to 3L/day if tolerated.
intervention. Teaching the patient to splint the affected area may
C. Administer cough suppressant q4hr.
also be helpful, but does not liquefy the secretions so that they
D. Teach patient to splint the affected area.
can be removed.
10. During discharge teaching for a 65-year-old patient with em-
physema and pneumonia, which of the following vaccines should
the nurse recommend the patient receive? C. Pneumococcal The pneumococcal vaccine is important for
A. S. aureus patients with a history of heart or lung disease, recovering from a
B. H. influenzae severe illness, age 65 or over, or living in a long-term care facility.
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. The nurse evaluates that discharge teaching for a patient hos-
pitalized with pneumonia has been most effective when the patient
D. "I should continue to do deep-breathing and coughing exercises
states which of the following measures to prevent a relapse?
for at least 6 weeks." It is important for the patient to continue
A. "I will increase my food intake to 2400 calories a day to keep
with coughing and deep breathing exercises for 6 to 8 weeks until
my immune system well."
all of the infection has cleared from the lungs. A patient should
B. "I must use home oxygen therapy for 3 months and then will
seek medical treatment for upper respiratory infections that persist
have a chest x-ray to reevaluate."
for more than 7 days. Increased fluid intake, not caloric intake,
C. "I will seek immediate medical treatment for any upper respi-
is required to liquefy secretions. Home O2 is not a requirement
ratory infections."
unless the patient's oxygenation saturation is below normal.
D. "I should continue to do deep-breathing and coughing exercises
for at least 6 weeks."
D. Sputum culture and sensitivityThe nurse should ensure that the
12. After admitting a patient to the medical unit with a diagnosis
sputum for culture and sensitivity was sent to the laboratory before
of pneumonia, the nurse will verify that which of the following
administering the cefotetan. It is important that the organisms are
physician orders have been completed before administering a
correctly identified (by the culture) before their numbers are affect-
dose of cefotetan (Cefotan) to the patient?
ed by the antibiotic; the test will also determine whether the proper
A. Serum laboratory studies ordered for AM
antibiotic has been ordered (sensitivity testing). Although antibiotic
B. Pulmonary function evaluation
administration should not be unduly delayed while waiting for the
C. Orthostatic blood pressures
patient to expectorate sputum, all of the other options will not be
D. Sputum culture and sensitivity
affected by the administration of antibiotics.
D. Positioning patient with "good lung down" Therapeutic posi-
13. Which of the following nursing interventions is most appropri- tioning identifies the best position for the patient assuring stable
ate to enhance oxygenation in a patient with unilateral malignant oxygenation status. Research indicates that positioning the patient
lung disease? with the unaffected lung (good lung) dependent best promotes
A. Positioning patient on right side. oxygenation in patients with unilateral lung disease. For bilateral
B. Maintaining adequate fluid intake lung disease, the right lung down has best ventilation and perfu-
C. Performing postural drainage every 4 hours sion. Increasing fluid intake and performing postural drainage will
D. Positioning patient with "good lung down" facilitate airway clearance, but positioning is most appropriate to
enhance oxygenation.
14. A 71-year-old patient is admitted with acute respiratory dis-
tress related to cor pulmonale. Which of the following nursing
interventions is most appropriate during admission of this patient?
C. Perform a physical assessment of the respiratory system and
A. Delay any physical assessment of the patient and review with
ask specific questions related to this episode of respiratory dis-
the family the patient's history of respiratory problems. B. Perform
tress.Because the patient is having respiratory difficulty, the nurse
a comprehensive health history with the patient to review prior
should ask specific questions about this episode and perform a
respiratory problems.
physical assessment of this system. Further history taking and
C. Perform a physical assessment of the respiratory system and
physical examination of other body systems can proceed once the
ask specific questions related to this episode of respiratory dis-
patient's acute respiratory distress is being managed.
tress.
D. Complete a full physical examination to determine the effect of
the respiratory distress on other body functions.
15. When planning appropriate nursing interventions for a patient
with metastatic lung cancer and a 60-pack-year history of ciga-
D. Mucociliary clearance Smoking decreases the ciliary action
rette smoking, the nurse recognizes that the smoking has most
in the tracheobronchial tree, resulting in impaired clearance of
likely decreased the patient's underlying respiratory defenses be-
respiratory secretions, chronic cough, and frequent respiratory
cause of impairment of which of the following?
infections.
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
, HESI MED SURG EXAM NEWEST 2024 200 QUESTIONS AND CORREC
DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+
Study online at https://quizlet.com/_fvcv7a
C. Cough reflex
D. Mucociliary clearance
16. While ambulating a patient with metastatic lung cancer, the
nurse observes a drop in oxygen saturation from 93% to 86%.
Which of the following nursing interventions is most appropriate
based upon these findings?
C. Obtain a physician's order for supplemental oxygen to be used
A. Continue with ambulation as this is a normal response to
during ambulation and other activity. An oxygen saturation level
activity.
that drops below 90% with activity indicates that the patient is not
B. Move the oximetry probe from the finger to the earlobe for more
tolerating the exercise and needs to have supplemental oxygen
accurate monitoring during activity.
applied.
C. Obtain a physician's order for supplemental oxygen to be used
during ambulation and other activity.
D. Obtain a physician's order for arterial blood gas determinations
to verify the oxygen saturation.
17. The nurse is caring for a 73-year-old patient who underwent
a left total knee arthroplasty. On the third postoperative day, the
patient complains of shortness of breath, slight chest pain, and
that "something is wrong." Temperature is 98.4o F, blood pressure
130/88, respirations 36, and oxygen saturation 91% on room B. Pulmonary embolus from deep vein thrombosis The patient
air. Which of the following should the nurse first suspect as the presents the classic symptoms of pulmonary embolus: acute on-
etiology of this episode? set of symptoms, tachypnea, shortness of breath, and chest pain.
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room
18. In the case of pulmonary embolus from deep vein thrombosis,
D. Sit the patient up in bed as tolerated and apply oxygen.The
which of the following actions should the nurse take first?
patient's clinical picture is consistent with pulmonary embolus, and
A. Notify the physician.
the first action the nurse takes should be to assist the patient. For
B. Administer a nitroglycerin tablet sublingually.
this reason, the nurse should sit the patient up as tolerated and
C. Conduct a thorough assessment of the chest pain.
apply oxygen before notifying the physician.
D. Sit the patient up in bed as tolerated and apply oxygen.
19. The nurse is caring for a postoperative patient with sudden
onset of respiratory distress. The physician orders a STAT venti-
lation-perfusion scan. Which of the following explanations should
A. This test involves injection of a radioisotope to outline the
the nurse provide to the patient about the procedure?
blood vessels in the lungs, followed by inhalation of a radioisotope
A. This test involves injection of a radioisotope to outline the blood
gas.A ventilation-perfusion scan has two parts. In the perfusion
vessels in the lungs, followed by inhalation of a radioisotope gas.
portion, a radioisotope is injected into the blood and the pulmonary
B. This test will use special technology to examine cross sections
vasculature is outlined. In the ventilation part, the patient inhales
of the chest with use of a contrast dye.
a radioactive gas that outlines the alveoli.
C. This test will use magnetic fields to produce images of the lungs
and chest. D. This test involves injecting contrast dye into a blood
vessel to outline the blood vessels of the lungs.
20. During assessment of a 45-year-old patient with asthma, the
nurse notes wheezing and dyspnea. The nurse interprets that C. Narrowing of the airwayNarrowing of the airway leads to re-
these symptoms are related to which of the following pathophysi- duced airflow, making it difficult for the patient to breathe and
ologic changes? A. Laryngospasm B. Overdistention of the alveoli producing the characteristic wheezing.
C. Narrowing of the airway D. Pulmonary edema
21. A 45-year-old man with asthma is brought to the emergency
department by automobile. He is short of breath and appears
frightened. During the initial nursing assessment, which of the
A. Anxiety An early symptom during an asthma attack is anxiety
following clinical manifestations might be present as an early
because he is acutely aware of the inability to get sufficient air to
symptom during an exacerbation of asthma?
breathe. He will be hypoxic early on with decreased PaCO2 and
A. Anxiety
increased pH as he is hyperventilating.
B. Cyanosis
C. Hypercapnia
D. Bradycardia
22. The nurse is assigned to care for a patient who has anxiety and
an exacerbation of asthma. Which of the following is the primary
reason for the nurse to carefully inspect the chest wall of this
