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Exam (elaborations) Med surg Medical-surgical Nurse Exam Flashcard Study System
Exam (elaborations) Med surg Medical-surgical Nurse Exam questions with correct answers.
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Med Surg Test bankPractice questions and 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 - 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.
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