HESI MED SURG V1 TEST BANK

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HESI MED SURG V1 TEST BANK

• The nurse assesses a patient with shortness of breath for evidence of

long-standing hypoxemia by inspecting:

• Chest excursion
• Spinal curvatures
• The respiratory pattern
• 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 by an increase in the depth, bulk, and sponginess of the end of the finger.

• 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?

• 2 minutes
• 5 minutes
• 10 minutes
• 15 minutes 1 / 8

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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.

• The nurse notices clear nasal drainage in a patient newly admitted with

facial trauma, including a nasal fracture. The nurse should:

• test the drainage for the presence of glucose.
• suction the nose to maintain airway clearance.
• document the findings and continue monitoring.
• apply a drip pad and reassure the patient this is normal.

ANS: 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.

• When caring for a patient who is 3 hours postoperative laryngectomy, the

nurse's highest priority assessment would be:

• Airway patency
• Patient comfort
• Incisional drainage
• Blood pressure and heart rate

ANS: 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. 2 / 8

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• When initially teaching a patient the supraglottic swallow following a

radical neck dissection, with which of the following foods should the nurse begin?

• Cola
• Applesauce
• French fries
• 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 pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice to start with.

• 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

• Ineffective thermoregulation related to chilling
• Ineffective breathing pattern related to pneumonia
• Ineffective airway clearance related to thick secretions

ANS: 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 3 / 8

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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.

• 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%

• Respiratory rate of 28
• Presence of greenish sputum
• Basilar crackles

ANS: 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.

• Which of the following clinical manifestations would the nurse expect to

find during assessment of a patient admitted with pneumococcal pneumonia?

• Hyperresonance on percussion
• Fine crackles in all lobes on auscultation
• Increased vocal fremitus on palpation D. Vesicular breath sounds in all 4 / 8