MedSurg NCLEX Exam BEST FINAL 2022/2023
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A patient with acute shortness of breath
is admitted to the hospital. Which action
should the nurse
... [Show More] take during the initial
assessment of the patient?
a.Ask the patient to lie down to complete
a full physical assessment.
b. Briefly ask specific questions about
this episode of respiratory distress.
c. Complete the admission database to
check for allergies before treatment.
d. Delay the physical assessment to first
complete pulmonary function tests
The nurse prepares a patient with a
left-sided pleural effusion for a thoracentesis. How should the nurse position the
patient?
a. Supine with the head of the bed elevated 30 degrees
b. In a high-Fowler's position with the left
arm extended
c. On the right side with the left arm
extended above the head
d. Sitting upright with the arms supported on an over bed table
A diabetic patient's arterial blood gas
(ABG) results are pH 7.28; PaCO2 34
mm Hg; PaO2 85 mm Hg; HCO3- 18
mEq/L. The nurse would expect which
finding?
a. Intercostal retractions
b. Kussmaul respirations
ANS: B
When a patient has severe respiratory distress, only information pertinent to
the current episode is obtained, and a
more thorough assessment is deferred
until later. Obtaining a comprehensive
health history or full physical examination is unnecessary until the acute distress has resolved.Brief questioning and
a focused physical assessment should
be done rapidly to help determine the
cause of the distress and suggest treatment. Checking for allergies is important, but it is not appropriate to complete
the entire admission database at this
time. The initial respiratory assessment
must be completed before any diagnostic tests or interventions can be ordered.
ANS: D
The upright position with the arms supported increases lung expansion, allows
fluid to collect at the lung bases, and
expands the intercostal space so that
access to the pleural space is easier.The
other positions would increase the work
of breathing for the patient and make it
more difficult for the health care provider
performing the thoracentesis.
ANS: B
Kussmaul (deep and rapid) respirations are a compensatory mechanism
for metabolic acidosis. The low pH and
low bicarbonate result indicate metabolic acidosis. Intercostal retractions, a low
oxygen saturation rate, and a decrease
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c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure
On auscultation of a patient's lungs,
the nurse hears low-pitched, bubbling
sounds during inhalation in the lower
third of both lungs. How should the nurse
document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c.Abnormal lung sounds in the apices of
both lungs
d. Pleural friction rub in the right and left
lower lobes
The nurse palpates the posterior chest
while the patient says "99" and notes
absent fremitus.Which action should the
nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough,
and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior
breath sounds bilaterally.
A patient with a chronic cough has
a bronchoscopy. After the procedure,
in venous O2 pressure would not be
caused by acidosis.
ANS: A
Crackles are low-pitched, bubbling
sounds usually heard on inspiration.
Wheezes are high-pitched sounds.They
can be heard during the expiratory or
inspiratory phase of the respiratory cycle. The lower third of both lungs are the
bases, not apices. Pleural friction rubs
are grating sounds that are usually heard
during both inspiration and expiration.
ANS: D
To assess for tactile fremitus, the nurse
should use the palms of the hands to
assess for vibration when the patient repeats a word or phrase such as "99."
After noting absent fremitus, the nurse
should then auscultate the lungs to assess for the presence or absence of
breath sounds. Absent fremitus may be
noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors,
thick bronchial secretions, and pleural
effusion. Turning, coughing, and deep
breathing is an appropriate intervention
for atelectasis, but the nurse needs to
first assess breath sounds. Fremitus is
decreased if the hand is farther from the
lung or the lung is hyperinflated (barrel
chest).The anterior of the chest is more
difficult to palpate for fremitus because
of the presence of large muscles and
breast tissue.
ANS: B
Risk for aspiration and maintaining an
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which intervention by the nurse is most
appropriate?
a.Elevate the head of the bed to 80 to 90
degrees.
b. Keep the patient NPO until the gag
reflex returns.
c. Place on bed rest for at least 4 hours
after bronchoscopy.
d. Notify the health care provider about
blood-tinged mucus.
The nurse completes a shift assessment
on a patient admitted in the early phase
of heart failure. When auscultating the
patient's lungs, which finding would the
nurse most likely hear?
a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical
sounds on inspiration and expiration
c.Discontinuous, high-pitched sounds of
short duration heard on inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration
While caring for a patient with respiratory disease, the nurse observes that
the patient's SpO2 drops from 93% to
88% while the patient is ambulating in
the hallway.What is the priority action of
the nurse?
a. Notify the health care provider.
b. Document the response to exercise.
c.Administer the PRN supplemental O2.
d. Encourage the patient to pace activity.
The nurse teaches a patient about pulmonary function testing (PFT). Which
statement, if made by the patient, indiopen airway is the priority. Because a
local anesthetic is used to suppress
the gag/cough reflexes during bronchoscopy, the nurse should monitor for
the return of these reflexes before allowing the patient to take oral fluids or food.
Blood-tinged mucus is not uncommon
after bronchoscopy.The patient does not
need to be on bed rest, and the head
of the bed does not need to be in the
high-Fowler's position.
ANS: C
Fine crackles are likely to be heard in
the early phase of heart failure. Fine
crackles are discontinuous, high-pitched
sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a
series of long-duration, discontinuous,
low-pitched sounds during inspiration.
Wheezes are continuous high-pitched
musical sounds on inspiration and expiration.
ANS: C
The drop in SpO2 to 85% indicates that
the patient is hypoxemic and needs supplemental oxygen when exercising. The
other actions are also important, but the
first action should b [Show Less]