Med Surg Test bank Read HESI Test
bank Med-Surg and other resources Complete Guaranteed 100% Answers
1. 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 - Ans-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 - Ans-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. - Ans-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 - Ans-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 - Ans-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 - Ans-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 - Ans-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
bank Med-Surg and other resources Complete Guaranteed 100% Answers
1. 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 - Ans-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 - Ans-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. - Ans-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 - Ans-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 - Ans-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 - Ans-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 - Ans-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
