MED SURG RN HESI EXIT EXAM 2024 VERSION 1
AND 2 /HESI RN MED SURG EXIT EXAM VERSION
1 AND 2 COMPLETE ALL 55 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
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 - ...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 - ...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. - ...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 -
...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 - ...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
AND 2 /HESI RN MED SURG EXIT EXAM VERSION
1 AND 2 COMPLETE ALL 55 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
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 - ...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 - ...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. - ...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 -
...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 - ...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
