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HESI MED SURG 2 EXAM ACTUAL EXAM ALL 200 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+$16.99
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The nurse assesses a patient D. The fingernail and its base Clubbing, a sign of long-
with shortness of breath for standing hypoxemia, is evidenced by an increase in the
evidence of long-standing angle between the base of the nail and the fingernail to
hypoxemia by inspecting: 180 degrees or more, usually accompanied by an
A. Chest excursion increase in the depth, bulk, and sponginess of the end of
B. Spinal curvatures the finger.
C. The respiratory pattern
D. The fingernail and its
base
2. The nurse is caring for a B. 5 minutes Following obtaining an arterial blood gas,
patient with COPD and the nurse should hold pressure on the puncture site for 5
pneumonia who has an minutes by the clock to be sure that bleeding has
order for arterial blood stopped. An artery is an elastic vessel under higher
gases to be drawn. Which pressure than veins, and significant blood loss or
of the following is the hematoma formation could occur if the time is
minimum length of time the insufficient.
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 A. test the drainage for the presence of glucose. Clear
nasal drainage in a patient nasal drainage suggests leakage of cerebrospinal fluid
newly admitted with facial (CSF). The drainage should be tested for the presence of
trauma, including a nasal glucose, which would indicate the presence of CSF.
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.
4. When caring for a patient A. Airway patency Remember ABCs with prioritization.
who is 3 hours Airway patency is always the highest priority and is
postoperative essential for a patient undergoing surgery surrounding
laryngectomy, the nurse's the upper respiratory system.
highest priority assessment
would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart
rate
5. When initially teaching a A. ColaWhen learning the supraglottic swallow, it may be
patient the supraglottic helpful to start with carbonated beverages because the
swallow following a radical effervescence provides clues about the liquid's position.
neck dissection, with which Thin, watery fluids should be avoided because they are
of the following foods difficult to swallow and increase the risk of aspiration.
should the nurse begin? Nonpourable pureed foods, such as applesauce, would
A. Cola decrease the risk of aspiration, but carbonated
B. Applesauce beverages are the better choice to start with.
C. French fries
D. White grape juice
,6. The nurse is caring for a A. Hyperthermia related to infectious illness Because the
patient admitted to the patient has spiked a temperature and has a diagnosis of
hospital with pneumonia. pneumonia, the logical nursing diagnosis is hyperthermia
Upon assessment, the nurse related to infectious illness. There is no evidence of a
notes a temperature of chill, and her breathing pattern is within normal limits at
101.4° F, a productive cough 20 breaths per minute. There is no evidence of
with yellow sputum and a ineffective airway clearance from the information given
respiratory rate of 20. Which because the patient is expectorating sputum.
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
7. Which of the following D. Basilar crackles The presence of adventitious breath
physical assessment sounds indicates that there is accumulation of secretions
findings in a patient with in the lower airways. This would be consistent with a
pneumonia best supports nursing diagnosis of ineffective airway clearance
the nursing diagnosis of because the patient is retaining secretions.
ineffective airway
clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish
sputum
D. Basilar crackles
, 8. Which of the following C. Increased vocal fremitus on palpation. A typical
clinical manifestations physical examination finding for a patient with
would the nurse expect to pneumonia is increased vocal fremitus on palpation.
find during assessment of a Other signs of pulmonary consolidation include dullness
patient admitted with to percussion, bronchial breath sounds, and crackles in
pneumococcal pneumonia? 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
9. Which of the following B. Increase fluid intake to 3L/day if tolerated. Although
nursing interventions is of several interventions may help the patient expectorate
the highest priority in mucus, the highest priority should be on increasing fluid
helping a patient intake, which will liquefy the secretions so that the
expectorate thick secretions patient can expectorate them more easily. Humidifying
related to pneumonia? the oxygen is also helpful, but is not the primary
A. Humidify the oxygen as intervention. Teaching the patient to splint the affected
able area may also be helpful, but does not liquefy the
B. Increase fluid intake to secretions so that they can be removed.
3L/day if tolerated.
C. Administer cough
suppressant q4hr.
D. Teach patient to splint
the affected area.
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