MEDSURG HESI TESTBANK WITH BEST EXPLANATIONS

MEDSURG HESI TESTBANK WITH BEST EXPLANATIONS

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)    

RATIONALE
 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.

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."    

"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.

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    

RATIONALE
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.

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    

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.

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    

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.

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.    

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.

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    

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.