ATI MED-SURG TEST BANK (RED HESI TEST BANK MED SURG) LATEST 2023-2024 QUESTIONS AND ANSWERS (CORRECT ANSWERS) WITH RATIONALES GRADED A+

ATI MED-SURG TEST
BANK (RED HESI TEST
BANK MED SURG)
LATEST 2023-2024
QUESTIONS AND
ANSWERS (CORRECT
ANSWERS) WITH
RATIONALES GRADED
A+





1. 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 - CORRECT
ANSWER-D.
RATIONALE-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 - CORRECT ANSWER-B.
RATIONALE- 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. - CORRECT ANSWER-A.
RATIONALE-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 - CORRECT
ANSWER-A.
RATIONALE- 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 - CORRECT ANSWER-A.
RATIONALE- 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 - CORRECT ANSWER-A.
RATIONALE- 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.