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Exam 2 directional termonolgy PPE/Isolation Review for Skills Chec... Chapte
13 terms 38 terms 11 terms 72 terms
raquel_ramos87 Preview gabriellaconde5 Preview jbs299 Preview smd
The nurse assesses a patient with shortness D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is
of breath for evidence of long-standing evidenced by an increase in the angle between the base of the nail and the
hypoxemia by inspecting: fingernail to 180 degrees or more, usually accompanied by an increase in the depth,
A. Chest excursion bulk, and sponginess of the end of the finger.
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base
See an expert-written answer!
2. The nurse is caring for a patient with B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold
COPD and pneumonia who has an order pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has
for arterial blood gases to be drawn. Which stopped. An artery is an elastic vessel under higher pressure than veins, and
of the following is the minimum length of significant blood loss or hematoma formation could occur if the time is insufficient.
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. The nurse notices clear nasal drainage in A. test the drainage for the presence of glucose. Clear nasal drainage suggests
a patient newly admitted with facial trauma, leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence
including a nasal fracture. The nurse should: of glucose, which would indicate the presence of CSF.
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. When caring for a patient who is 3 hours A. Airway patency Remember ABCs with prioritization. Airway patency is always the
postoperative laryngectomy, the nurse's highest priority and is essential for a patient undergoing surgery surrounding the
highest priority assessment would be: upper respiratory system.
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
See an expert-written answer!
5. When initially teaching a patient the A. ColaWhen learning the supraglottic swallow, it may be helpful to start with
supraglottic swallow following a radical carbonated beverages because the effervescence provides clues about the liquid's
neck dissection, with which of the following position. Thin, watery fluids should be avoided because they are difficult to swallow
foods should the nurse begin? and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce,
A. Cola would decrease the risk of aspiration, but carbonated beverages are the better
B. Applesauce choice to start with.
C. French fries
D. White grape juice
See an expert-written answer!
6. The nurse is caring for a patient admitted A. Hyperthermia related to infectious illness Because the patient has spiked a
to the hospital with pneumonia. Upon temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is
assessment, the nurse notes a temperature hyperthermia related to infectious illness. There is no evidence of a chill, and her
of 101.4° F, a productive cough with yellow breathing pattern is within normal limits at 20 breaths per minute. There is no
sputum and a respiratory rate of 20. Which evidence of ineffective airway clearance from the information given because the
of the following nursing diagnosis is most patient is expectorating sputum.
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. Which of the following physical D. Basilar crackles The presence of adventitious breath sounds indicates that there is
assessment findings in a patient with accumulation of secretions in the lower airways. This would be consistent with a
pneumonia best supports the nursing nursing diagnosis of ineffective airway clearance because the patient is retaining
diagnosis of ineffective airway clearance? secretions.
A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
See an expert-written answer!
8. Which of the following clinical C. Increased vocal fremitus on palpation. A typical physical examination finding for a
manifestations would the nurse expect to patient with pneumonia is increased vocal fremitus on palpation. Other signs of
find during assessment of a patient pulmonary consolidation include dullness to percussion, bronchial breath sounds,
admitted with pneumococcal pneumonia? and crackles in the affected area.
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
See an expert-written answer!
9. Which of the following nursing B. Increase fluid intake to 3L/day if tolerated. Although several interventions may
interventions is of the highest priority in help the patient expectorate mucus, the highest priority should be on increasing
helping a patient expectorate thick fluid intake, which will liquefy the secretions so that the patient can expectorate
secretions related to pneumonia? them more easily. Humidifying the oxygen is also helpful, but is not the primary
A. Humidify the oxygen as able intervention. Teaching the patient to splint the affected area may also be helpful, but
B. Increase fluid intake to 3L/day if does not liquefy the secretions so that they can be removed.
tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area.
See an expert-written answer!
10. During discharge teaching for a 65- C. Pneumococcal The pneumococcal vaccine is important for patients with a history
year-old patient with emphysema and of heart or lung disease, recovering from a severe illness, age 65 or over, or living in
pneumonia, which of the following vaccines a long-term care facility.
should the nurse recommend the patient
receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
See an expert-written answer!
Med Surg Test bank ( Red HESI Test bank
Med-Surg and other resources)
Save
Students also studied
Flashcard sets Study guides Practice tests
Exam 2 directional termonolgy PPE/Isolation Review for Skills Chec... Chapte
13 terms 38 terms 11 terms 72 terms
raquel_ramos87 Preview gabriellaconde5 Preview jbs299 Preview smd
The nurse assesses a patient with shortness D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is
of breath for evidence of long-standing evidenced by an increase in the angle between the base of the nail and the
hypoxemia by inspecting: fingernail to 180 degrees or more, usually accompanied by an increase in the depth,
A. Chest excursion bulk, and sponginess of the end of the finger.
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base
See an expert-written answer!
2. The nurse is caring for a patient with B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold
COPD and pneumonia who has an order pressure on the puncture site for 5 minutes by the clock to be sure that bleeding has
for arterial blood gases to be drawn. Which stopped. An artery is an elastic vessel under higher pressure than veins, and
of the following is the minimum length of significant blood loss or hematoma formation could occur if the time is insufficient.
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. The nurse notices clear nasal drainage in A. test the drainage for the presence of glucose. Clear nasal drainage suggests
a patient newly admitted with facial trauma, leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence
including a nasal fracture. The nurse should: of glucose, which would indicate the presence of CSF.
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. When caring for a patient who is 3 hours A. Airway patency Remember ABCs with prioritization. Airway patency is always the
postoperative laryngectomy, the nurse's highest priority and is essential for a patient undergoing surgery surrounding the
highest priority assessment would be: upper respiratory system.
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
See an expert-written answer!
5. When initially teaching a patient the A. ColaWhen learning the supraglottic swallow, it may be helpful to start with
supraglottic swallow following a radical carbonated beverages because the effervescence provides clues about the liquid's
neck dissection, with which of the following position. Thin, watery fluids should be avoided because they are difficult to swallow
foods should the nurse begin? and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce,
A. Cola would decrease the risk of aspiration, but carbonated beverages are the better
B. Applesauce choice to start with.
C. French fries
D. White grape juice
See an expert-written answer!
6. The nurse is caring for a patient admitted A. Hyperthermia related to infectious illness Because the patient has spiked a
to the hospital with pneumonia. Upon temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is
assessment, the nurse notes a temperature hyperthermia related to infectious illness. There is no evidence of a chill, and her
of 101.4° F, a productive cough with yellow breathing pattern is within normal limits at 20 breaths per minute. There is no
sputum and a respiratory rate of 20. Which evidence of ineffective airway clearance from the information given because the
of the following nursing diagnosis is most patient is expectorating sputum.
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. Which of the following physical D. Basilar crackles The presence of adventitious breath sounds indicates that there is
assessment findings in a patient with accumulation of secretions in the lower airways. This would be consistent with a
pneumonia best supports the nursing nursing diagnosis of ineffective airway clearance because the patient is retaining
diagnosis of ineffective airway clearance? secretions.
A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
See an expert-written answer!
8. Which of the following clinical C. Increased vocal fremitus on palpation. A typical physical examination finding for a
manifestations would the nurse expect to patient with pneumonia is increased vocal fremitus on palpation. Other signs of
find during assessment of a patient pulmonary consolidation include dullness to percussion, bronchial breath sounds,
admitted with pneumococcal pneumonia? and crackles in the affected area.
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
See an expert-written answer!
9. Which of the following nursing B. Increase fluid intake to 3L/day if tolerated. Although several interventions may
interventions is of the highest priority in help the patient expectorate mucus, the highest priority should be on increasing
helping a patient expectorate thick fluid intake, which will liquefy the secretions so that the patient can expectorate
secretions related to pneumonia? them more easily. Humidifying the oxygen is also helpful, but is not the primary
A. Humidify the oxygen as able intervention. Teaching the patient to splint the affected area may also be helpful, but
B. Increase fluid intake to 3L/day if does not liquefy the secretions so that they can be removed.
tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area.
See an expert-written answer!
10. During discharge teaching for a 65- C. Pneumococcal The pneumococcal vaccine is important for patients with a history
year-old patient with emphysema and of heart or lung disease, recovering from a severe illness, age 65 or over, or living in
pneumonia, which of the following vaccines a long-term care facility.
should the nurse recommend the patient
receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
See an expert-written answer!
