Med Surg Test bank ( Red HESI Test bank
Med-Surg and other resources)
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.
9. 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.
,B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help
the patient expectorate mucus, the highest priority should be on increasing fluid intake,
which will liquefy the secretions so that the patient can expectorate them more easily.
Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the
patient to splint the affected area may also be helpful, but does not liquefy the
secretions so that they can be removed.
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)
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.
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."
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.
12. 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
D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture
and sensitivity was sent to the laboratory before administering the cefotetan. It is
important that the organisms are correctly identified (by the culture) before their
numbers are affected by the antibiotic; the test will also determine whether the proper
antibiotic has been ordered (sensitivity testing). Although antibiotic administration
should not be unduly delayed while waiting for the patient to expectorate sputum, all of
the other options will not be affected by the administration of antibiotics.
, 13. Which of the following nursing interventions is most appropriate to enhance
oxygenation in a patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down"
D. Positioning patient with "good lung down" Therapeutic positioning identifies the best
position for the patient assuring stable oxygenation status. Research indicates that
positioning the patient with the unaffected lung (good lung) dependent best promotes
oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right
lung down has best ventilation and perfusion. Increasing fluid intake and performing
postural drainage will facilitate airway clearance, but positioning is most appropriate to
enhance oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress related to cor
pulmonale. Which of the following nursing interventions is most appropriate
during admission of this patient?
A. Delay any physical assessment of the patient and review with the family the
patient's history of respiratory problems. B. Perform a comprehensive health
history with the patient to review prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific
questions related to this episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory
distress on other body functions.
C. Perform a physical assessment of the respiratory system and ask specific questions
related to this episode of respiratory distress.Because the patient is having respiratory
difficulty, the nurse should ask specific questions about this episode and perform a
physical assessment of this system. Further history taking and physical examination of
other body systems can proceed once the patient's acute respiratory distress is being
managed.
15. When planning appropriate nursing interventions for a patient with metastatic
lung cancer and a 60-pack-year history of cigarette smoking, the nurse
recognizes that the smoking has most likely decreased the patient's underlying
respiratory defenses because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance
D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial
tree, resulting in impaired clearance of respiratory secretions, chronic cough, and
frequent respiratory infections.
16. While ambulating a patient with metastatic lung cancer, the nurse observes a
drop in oxygen saturation from 93% to 86%. Which of the following nursing
interventions is most appropriate based upon these findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate
monitoring during activity.
Med-Surg and other resources)
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.
9. 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.
,B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help
the patient expectorate mucus, the highest priority should be on increasing fluid intake,
which will liquefy the secretions so that the patient can expectorate them more easily.
Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the
patient to splint the affected area may also be helpful, but does not liquefy the
secretions so that they can be removed.
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)
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.
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."
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.
12. 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
D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture
and sensitivity was sent to the laboratory before administering the cefotetan. It is
important that the organisms are correctly identified (by the culture) before their
numbers are affected by the antibiotic; the test will also determine whether the proper
antibiotic has been ordered (sensitivity testing). Although antibiotic administration
should not be unduly delayed while waiting for the patient to expectorate sputum, all of
the other options will not be affected by the administration of antibiotics.
, 13. Which of the following nursing interventions is most appropriate to enhance
oxygenation in a patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down"
D. Positioning patient with "good lung down" Therapeutic positioning identifies the best
position for the patient assuring stable oxygenation status. Research indicates that
positioning the patient with the unaffected lung (good lung) dependent best promotes
oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right
lung down has best ventilation and perfusion. Increasing fluid intake and performing
postural drainage will facilitate airway clearance, but positioning is most appropriate to
enhance oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress related to cor
pulmonale. Which of the following nursing interventions is most appropriate
during admission of this patient?
A. Delay any physical assessment of the patient and review with the family the
patient's history of respiratory problems. B. Perform a comprehensive health
history with the patient to review prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific
questions related to this episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory
distress on other body functions.
C. Perform a physical assessment of the respiratory system and ask specific questions
related to this episode of respiratory distress.Because the patient is having respiratory
difficulty, the nurse should ask specific questions about this episode and perform a
physical assessment of this system. Further history taking and physical examination of
other body systems can proceed once the patient's acute respiratory distress is being
managed.
15. When planning appropriate nursing interventions for a patient with metastatic
lung cancer and a 60-pack-year history of cigarette smoking, the nurse
recognizes that the smoking has most likely decreased the patient's underlying
respiratory defenses because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance
D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial
tree, resulting in impaired clearance of respiratory secretions, chronic cough, and
frequent respiratory infections.
16. While ambulating a patient with metastatic lung cancer, the nurse observes a
drop in oxygen saturation from 93% to 86%. Which of the following nursing
interventions is most appropriate based upon these findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate
monitoring during activity.
