ADVANCED MED SURG TEST BANK (
RED HESI TEST BANK MED-SURG AND
OTHER RESOURCES) WITH VALID
QUESTIONS PHRASED WITH
APPROPRIATE ANSWERS
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 ANSWER-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 -CORRECT ANSWER-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 insu icient.
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 ANSWER-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 -CORRECT ANSWER-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 -CORRECT ANSWER-A. ColaWhen learning the supraglottic swallow, it
may be helpful to start with carbonated beverages because the e ervescence provides
clues about the liquid's position. Thin, watery fluids should be avoided because they are
di icult 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. Ine ective thermoregulation related to chilling
C. Ine ective breathing pattern related to pneumonia
D. Ine ective airway clearance related to thick secretions -CORRECT ANSWER-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 ine ective 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 ine ective airway clearance? A. Oxygen saturation of
85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles -CORRECT ANSWER-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 ine ective 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
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -CORRECT
ANSWER-C. Increased vocal fremitus on palpation. A typical physical examination finding
for 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 a ected area.
, 9. Which of the following nursing interventions is of the highest priority in helping a patient
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 a ected area. -CORRECT ANSWER-B. Increase fluid intake to
3L/day if tolerated. Although several interventions may help the patient expectorate mucus,
the highest priority should be on increasing fluid intake, which will liquefy the secretions so
that the patient can expectorate them more easily. Humidifying the oxygen is also helpful,
but is not the primary intervention. Teaching the patient to splint the a ected area may also
be helpful, but does not liquefy the secretions so that they can be removed.
10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia,
which 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 ANSWER-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 with pneumonia
has been most e ective 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 6 weeks." -
CORRECT ANSWER-D. "I should continue to do deep-breathing and coughing exercises for
RED HESI TEST BANK MED-SURG AND
OTHER RESOURCES) WITH VALID
QUESTIONS PHRASED WITH
APPROPRIATE ANSWERS
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 ANSWER-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 -CORRECT ANSWER-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 insu icient.
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 ANSWER-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 -CORRECT ANSWER-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 -CORRECT ANSWER-A. ColaWhen learning the supraglottic swallow, it
may be helpful to start with carbonated beverages because the e ervescence provides
clues about the liquid's position. Thin, watery fluids should be avoided because they are
di icult 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. Ine ective thermoregulation related to chilling
C. Ine ective breathing pattern related to pneumonia
D. Ine ective airway clearance related to thick secretions -CORRECT ANSWER-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 ine ective 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 ine ective airway clearance? A. Oxygen saturation of
85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles -CORRECT ANSWER-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 ine ective 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
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -CORRECT
ANSWER-C. Increased vocal fremitus on palpation. A typical physical examination finding
for 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 a ected area.
, 9. Which of the following nursing interventions is of the highest priority in helping a patient
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 a ected area. -CORRECT ANSWER-B. Increase fluid intake to
3L/day if tolerated. Although several interventions may help the patient expectorate mucus,
the highest priority should be on increasing fluid intake, which will liquefy the secretions so
that the patient can expectorate them more easily. Humidifying the oxygen is also helpful,
but is not the primary intervention. Teaching the patient to splint the a ected area may also
be helpful, but does not liquefy the secretions so that they can be removed.
10. During discharge teaching for a 65-year-old patient with emphysema and pneumonia,
which 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 ANSWER-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 with pneumonia
has been most e ective 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 6 weeks." -
CORRECT ANSWER-D. "I should continue to do deep-breathing and coughing exercises for
