Med Surg Test bank ( Red HESI Test
bank Med-Surg and other resources)
Latest Update
Rationale:
Treatment of flail chest is focused on preventing atelectasis and related complications of compromised
ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients
with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option
C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who
require mechanical ventilation. Option A should not be withheld. Option B should not be applied
because the fractures are clearly visible on the chest radiograph.
Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to
the hospital for a new-onset cardiac dysrhythmia?
A.Diarrhea related to medication side effects
B.Anxiety related to fear of recurrent anginal episodes
C.Altered nutrition related to high serum lipid levels
D.Risk for injury related to syncope and confusion - ANSWER-D.Risk for injury related to syncope and
confusion
1. A nurse is reviewing the hematologic test results for a patient in whom the hematocrit (Hct) is
reported at a reading of 30%. Based on this result, the nurse should interpret that the patient
A. is susceptible to bleeding disorders.
B. has fewer red blood cells than normal. C. is experiencing an inflammatory response.
D. is experiencing an acute hemolytic crisis. - ANSWER-B. has fewer red blood cells than normal.The Hct
is the measure of the volume of red blood cells in whole blood expressed as a percentage. This test is
useful in the diagnosis of anemia, polycythemia, and abnormal hydration states. Patients who are
susceptible to bleeding disorders likely will have a low platelet count. The inflammatory response may
best be evaluated by examination of results that include the white blood cell count with differential
analysis. Acute hemolytic crisis develops in patients receiving blood components in which
incompatibility occurs or in patients with bleeding disorders or conditions that promote cellular damage,
such as damage associated with shock.
1. The arterial blood gas (ABG) readings that indicate compensated respiratory acidosis are a PaCO2 of
A. 30 mm Hg and bicarbonate level of 24 mEq/L.
B. 30 mm Hg and bicarbonate level of 30 mEq/L.
,Med Surg Test bank ( Red HESI Test
bank Med-Surg and other resources)
Latest Update
C. 50 mm Hg and bicarbonate level of 20 mEq/L.
D. 50 mm Hg and bicarbonate level of 30 mEq/L. - ANSWER-D. 50 mm Hg and bicarbonate level of 30
mEq/L. If compensation is present, carbon dioxide and bicarbonate are abnormal (or nearly so) in
opposite directions (e.g., one is acidotic and the other alkalotic).
1. When assessing a patient's nutritional-metabolic pattern related to hematologic health, the nurse
would:
A. Inspect the skin for petechiae.
B. Ask the patient about joint pain.
C. Assess for vitamin C deficiency.
D. Determine if the patient can perform ADLs. - ANSWER-A. Inspect the skin for petechiae. Any changes
in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic
pattern related to hematologic health. The presences of petechiae or ecchymotic areas could be
indicative of hematologic deficiencies related to poor nutritional intake or related causes.
10. Anticoagulant therapy is used in the treatment of thromboembolic disease because anticoagulants
can
A. dissolve the thrombi.
B. decrease blood viscosity.
C. prevent absorption of vitamin K.
D. inhibit the synthesis of clotting factors. - ANSWER-D. inhibit the synthesis of clotting factors.
Anticoagulant therapy is based on the premise that the initiation or extension of thrombi can be
prevented by inhibiting the synthesis of clotting factors or by accelerating their inactivation. The
anticoagulants heparin and warfarin do not induce thrombolysis but effectively prevent clot extension.
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) - 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.
,Med Surg Test bank ( Red HESI Test
bank Med-Surg and other resources)
Latest Update
10. If a nurse is caring for an 80-year-old patient with a temperature of 100.4° F, crackles at the right
lung base, pain with deep inspiration, and dyspnea, which of the following orders is the nurse's priority?
A. Sputum specimen for culture and sensitivity
B. Codeine 15 mg orally every 6 hours as needed
C. Incentive spirometer every 2 hours while awake
D. Amoxicillin (Amoxil) 500 mg orally 4 times a day - ANSWER-A. Sputum specimen for culture and
sensitivity The patient presents with signs of a respiratory infection. To initiate the most effective
therapy, the health care prescriber must know the pathogen causing the infection. Therefore, the
sputum specimen is the nurse's priority. If the antibiotic is administered before the specimen is
obtained, the results of the culture might not be as accurate and could impair the effectiveness of
therapy. After the specimen is obtained, the nurse can administer codeine for coughing and begin the
incentive spirometry to mobilize secretions and improve the patient's ability to expectorate the
secretions.
10. The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are
ready for pick up. The nurse should take which of the following actions to prevent an adverse effect
during this procedure?
A. Immediately pick up both units of blood from the blood bank.
B. Regulate the flow rate so that each unit takes at least 4 hours to transfuse.
C. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
D. Infuse the blood slowly for the first 15 minutes of the transfusion. - ANSWER-D. Infuse the blood
slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur
at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2
ml/min and remain with the patient for the first 15 minutes after hanging a unit of blood.
11. If a patient has pernicious anemia, the nurse should provide information regarding
A. frequent bouts of dyspnea.
B. risks relative to dehydration.
C. deficiency of intrinsic factor.
D. lack of any effective treatment for this condition. - ANSWER-C. deficiency of intrinsic factor.
Pernicious anemia is a type of anemia caused by failure of absorption of vitamin B12 (cobalamin). The
most common cause is lack of intrinsic factor, a glucoprotein produced by the parietal cells of the gastric
lining.
, Med Surg Test bank ( Red HESI Test
bank Med-Surg and other resources)
Latest Update
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." - ANSWER-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.
11. When assessing a patient's respiratory status, which of the following nonrespiratory data are most
important for the nurse to obtain?
A. Height and weight
B. Neck circumference
C. Occupation and hobbies
D. Usual daily fluid intake - ANSWER-C. Occupation and hobbiesMany respiratory problems occur as a
result of chronic exposure to inhalation irritants. Common occupational sources of inhalation irritants
include mines, granaries, farms, lawn care companies, paint, plastics and rubber manufacture, and
building remodeling. Hobbies associated with inhalation irritants include woodworking, metal finishing,
furniture refinishing, painting, and ceramics. Daily fluids, height, and weight are more related to
respiratory problems secondary to cardiac issues.
12. A nurse is providing care to an adult female patient and observes that the Hb laboratory analysis
result is 9 g/dl. Based on this finding, the nurse should expect to observe
A. dyspnea.
B. bradycardia.
C. warm, dry skin.
D. activity tolerance without complaint of fatigue. - ANSWER-A. dyspnea.Hb levels are used to
determine the severity of anemia. Patients with moderate anemia (Hb 6 to 10 g/dL) may suffer from
dyspnea, palpitations, diaphoresis with exertion, and chronic fatigue. Patients who are anemic usually
have cool skin related to compensatory mechanism of mild vasoconstriction. Patients who are anemic
