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HESI Med Surg Test bank
- 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
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D. 15 minutes: B. 5 minutes Following obtaining an arterial blood gas, thenurse 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 vesselunder 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 thedrainage for the presence of glucose. Clear nasal drainage suggestsleakage of cerebrospinal fluid (CSF). The drainage should be tested forthe 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.
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- 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. 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: 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
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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
clear- ance? 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