Med Surg Test bank NCLEX/ Red HESI Test bank Med-Surg (Solved/rationales
11 views 0 purchase
Course
Med Surg NCLEX T-bank
Institution
Rasmussen College
Med Surg Test bank NCLEX/ Red HESI Test bank Med-Surg (Solved/rationales)
1The 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 D. The f...
med surg test bank nclex red hesi test bank med surg solvedrationales 1the nurse assesses a patient with shortness of breath for evidence of long standing hypoxemia by inspecting a chest excurs
Written for
Rasmussen College
Med Surg NCLEX T-bank
All documents for this subject (11)
Seller
Follow
ACADEMICAIDSTORE
Reviews received
Content preview
Med Surg Test bank NCLEX/ Red HESI Test bank
Med-Surg (Solved/rationales)
1The 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 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 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. 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 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 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 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 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
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes
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 affected 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 affected area. 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 affected 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) 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 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 6
weeks." D. "I should continue to do deep-breathing and coughing exercises for
at least 6 weeks." It is important for the patient to continue with coughing and deep
breathing exercises for 6 to 8 weeks until all of the infection has cleared from the
lungs. A patient should seek medical treatment for upper respiratory infections that
, persist for more than 7 days. Increased fluid intake, not caloric intake, is required
to liquefy 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, the
nurse will verify that which of the following physician orders have been completed
before administering a dose of cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity D. Sputum culture and sensitivityThe nurse
should ensure that the sputum for culture and sensitivity was sent to the laboratory
before administering the cefotetan. It is important that the organisms are correctly
identified (by the culture) before their numbers are affected by the antibiotic; the
test will also determine whether the proper antibiotic has been ordered (sensitivity
testing). Although antibiotic administration should not be unduly delayed while
waiting for the patient to expectorate sputum, all of the other options will not be
affected by the administration of antibiotics.
13. Which of the following nursing interventions is most appropriate to enhance
oxygenation in a patient with unilateral malignant lung 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" D. Positioning patient with
"good lung down" Therapeutic positioning identifies the best position for the
patient assuring stable oxygenation status. Research indicates that positioning the
patient with the 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 will facilitate airway 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
during admission of 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 the patient to review 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. C. Perform a physical assessment of the
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ACADEMICAIDSTORE. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $12.49. You're not tied to anything after your purchase.
