HESI RN MED SURGE EXIT EXAM | Questions and answers | 2022

. When assessing a patient'srespiratory 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 26.If a nurse is assessing a patient whose recent blood gas determination indicated a pH of 7.32 and respirations are measured at 32 breaths/min, which of the following isthe most appropriate nursing assessment? A. The rapid breathing is causing the low pH. B. The nurse should sedate the patient to slow down respirations. C. The rapid breathing is an attempt to compensate for the low pH. D. The nurse should give the patient a paper bag to breathe into to correct the low pH. 27) If a patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube, a nurse should first A. call the physician. B. attempt to reinsert the tracheostomy tube. C. position the patient in a lateral position with the neck extended. D. cover the stoma with a sterile dressing and ventilate the patient with a manual bag-mask until the physician arrives. 28.) Upon entering the room of a patient who has just returned from surgery for total laryngectomy and radical neck dissection, a nurse should recognize a need for intervention when finding A. a gastrostomy tube that is clamped. B. the patient coughing blood-tinged secretionsfrom the tracheostomy. C. the patient positioned in a lateral position with the head of the bed flat. D. 200 ml ofserosanguineous drainage in the patient's portable drainage device. 29) When administering oxygen to a patient with COPD with the potential for carbon dioxide narcosis, the nurse should A. never administer oxygen at a rate of more than 2 L/min. B. monitor the patient's use of oxygen to detect oxygen dependency. C. monitorthe patient forsymptoms of oxygen toxicity,such as paresthesias. D. use ABGs as a guide to determine what FIO2 level meets the patient's needs. 30) To ensure the correct amount of oxygen delivery for a patient receiving 35% oxygen via a Venturi mask, it is most important that the nurse A. keep the air-entrainment ports clean and unobstructed. B. apply an adaptor to increase humidification of the oxygen. C. drain moisture condensation from the oxygen tubing every hour. D. keep the flow rate high enough to keep the bag from collapsing during inspiration. 31) While caring for a patient with respiratory disease, a nurse observes that the oxygen saturation dropsfrom 94% to 85% when the patient ambulates. The nurse should determine that A. supplemental oxygen should be used when the patient exercises. B. ABG determinations should be done to verify the oxygen saturation reading. C. this finding is a normal response to activity and that the patient should continue to be monitored. D. the oximetry probe should be moved from the finger to the earlobe for an accurate oxygen saturation measurement during activity. 32) A nurse establishesthe presence of a tension pneumothorax when assessment findings reveal a(n) A. absence of lung sounds on the affected side. B. inability to auscultate tracheal breath sounds. C. deviation of the trachea toward the side opposite the pneumothorax. D. shift of the point of maximal impulse (PMI) to the left, with bounding pulses. 33) Which of the following statements made by a nurse would indicate proper teaching principles regarding feeding and tracheostomies? A. "Follow each spoon of food consumed with a drink of fluid." B. "Thin your foodsto a liquid consistency whenever possible." C. "Tilt your chin forward toward the chest when swallowing your food." D. "Make sure your cuff is overinflated before eating if you have swallowing problems." 34) If a patientstates, "It's hard for me to breathe and I feelshort-winded all the time," what is the most appropriate terminology to be applied in documenting this assessment by a nurse? A. Apnea B. Dyspnea C. Tachypnea D. Respiratory fatigue 35)To prevent atelectasis in an 82-year-old patient with a hip fracture, a nurse should A. supply oxygen. B. suction the upper airway. C. ambulate the patient frequently. D. assist the patient with aggressive coughing and deep breathing. 36) Which of the following physical assessment findings in a patient with pneumonia best supportsthe nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28 C. Presence of greenish sputum D. Basilar crackles 37) 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 38) Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area. 39) 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) 40) The nurse evaluatesthat 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 willseek immediate medical treatment for any upper respiratory infections." D. "Ishould continue to do deep-breathing and coughing exercises for at least 6 weeks." 41) After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient? A. Serum laboratory studies ordered for AM B. Pulmonary function evaluation C. Orthostatic blood pressures D. Sputum culture and sensitivity