HESI MED SURG V1 TEST BANK
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 byan increase in the
depth, bulk, and sponginess of the end of the finger.
2. 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. 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 drainagefor the presence of glucose. Clear nasal drainage
suggests leakage of cerebrospinalfluid (CSF). The drainage should be tested for the
presence of glucose, which wouldindicate the presence of CSF.
4. 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 apatient undergoing surgery
surrounding the upper respiratory system.
,5. 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 pureedfoods, such as
applesauce, would decrease the risk of aspiration, but carbonated beverages are
the better choice to start with.
6. 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. Hy-
perthermia 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 hasa 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 withinnormal 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. 7. Which of the following physical assessment findings in a patient with
pneumonia best supports the nursing diagnosis of ineffective airway clear-
ance? 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 soundsindicates 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. 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
ANS: 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. 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.
ANS: B. Increase fluid intake to 3L/day iftolerated. 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 sothat they can be removed.
10. 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)
ANS: C. Pneumococcal The pneumococcal vaccineis 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. 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 infec-
tions."
D. "I should continue to do deep-breathing and coughing exercises for at least
6 weeks."
ANS: 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. 12. After admitting a patient to the medical unit with a diagnosis of pneumo-
nia, 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
ANS: D. Sputum culture and sensitivityThe nurse should ensure that the sputum
for culture and sensitivity was sent to the laboratorybefore 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. 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"
ANS: D. Positioning patient with "goodlung down" Therapeutic positioning
identifies the best position for the patient assur-ing 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 bestventilation and
perfusion. Increasing fluid intake and performing postural drainage will facilitate
airway clearance, but positioning is most appropriate to enhance oxygenation.
14. 14. A 71-year-old patient is admitted with acute respiratory distress related
to cor pulmonale. Which of the following nursing interventions is most appro-
priate 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 respira-
