HESI Med Surg EXAM COMPLETE
QUESTIONS AND ANSWERS |
ALREADY PASSED | 2025 LATEST!!
The nurse assesses a patient with shortness of breath for evidence of long-
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standing hypoxemia by inspecting: QW QW QW
A. Chest excursion
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B. Spinal curvatures
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C. The respiratory pattern
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D. The fingernail and its base - CORRECT ANSWER-
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D. The fingernail and its base Clubbing, a sign of long-
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standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the
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fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and spo
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nginess of the end of the finger.QW QW QW QW QW QW
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood
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gases to be drawn. Which of the following is the minimum length of time the nurse should plan to
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hold pressure on the puncture site?
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A. 2 minutes
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B. 5 minutes
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C. 10 minutes
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D. 15 minutes - CORRECT ANSWER-
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B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the punc
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ture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic ve
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ssel under higher pressure than veins, and significant blood loss or hematoma formation could occ
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ur if the time is insufficient.
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3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including
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a nasal fracture. The nurse should:
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A. test the drainage for the presence of glucose.
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B. suction the nose to maintain airway clearance.
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C. document the findings and continue monitoring.
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D. apply a drip pad and reassure the patient this is normal. - CORRECT ANSWER-
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A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebros
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pinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate t
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he presence of CSF.
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,4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priorit
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y assessment would be:
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A. Airway patency
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B. Patient comfort
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C. Incisional drainage
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D. Blood pressure and heart rate - CORRECT ANSWER-
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A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priorit
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y and is essential for a patient undergoing surgery surrounding the upper respiratory system.
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5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, wit
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h which of the following foods should the nurse begin?
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A. Cola QW
B. Applesauce
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C. French fries
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D. White grape juice - CORRECT ANSWER-
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A. ColaWhen learning the supraglottic swallow, it may be helpful to start with carbonated beverag
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es because the effervescence provides clues about the liquid's position. Thin, watery fluids should
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be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable p
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ureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages
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are the better choice to start with.
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6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, th
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e nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory
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rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessme
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nt? A. Hyperthermia related to infectious illness
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B. Ineffective thermoregulation related to chilling
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C. Ineffective breathing pattern related to pneumonia
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D. Ineffective airway clearance related to thick secretions - CORRECT ANSWER-
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A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has
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a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illnes
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s. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths p
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er minute. There is no evidence of ineffective airway clearance from the information given becaus
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e the patient is expectorating sputum.
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7. Which of the following physical assessment findings in a patient with pneumonia best supports t
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he nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
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B. Respiratory rate of 28
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C. Presence of greenish sputum
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D. Basilar crackles - CORRECT ANSWER-
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D. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation
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,Wof secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective
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Wairway clearance because the patient is retaining secretions.
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8. Which of the following clinical manifestations would the nurse expect to find during assessment
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of a patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
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B. Fine crackles in all lobes on auscultation
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C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -
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CORRECT ANSWER-
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C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with p
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neumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include
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dullness to percussion, bronchial breath sounds, and crackles in the affected area.
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9. Which of the following nursing interventions is of the highest priority in helping a patient expect
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orate thick secretions related to pneumonia?
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A. Humidify the oxygen as able
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B. Increase fluid intake to 3L/day if tolerated.
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C. Administer cough suppressant q4hr.
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D. Teach patient to splint the affected area. - CORRECT ANSWER-
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B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient
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expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the
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secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also he
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lpful, but is not the primary intervention. Teaching the patient to splint the affected area may also
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be helpful, but does not liquefy the secretions so that they can be removed.
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10. During discharge teaching for a 65-year-
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old patient with emphysema and pneumonia, which of the following vaccines should the nurse rec
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ommend the patient receive? QW QW QW
A. S. aureus
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B. H. influenzae
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C. Pneumococcal
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D. Bacille Calmette-Guérin (BCG) - CORRECT ANSWER-
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C. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lun
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g disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.
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11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has bee
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n most effective when the patient states which of the following measures to prevent a relapse?
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A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
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B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."
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C. "I will seek immediate medical treatment for any upper respiratory infections."
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D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." -
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CORRECT ANSWER-D. "I should continue to do deep-
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breathing and coughing exercises for at least 6 weeks." It is important for the patient to continue
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, with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared f
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rom the lungs. A patient should seek medical treatment for upper respiratory infections that persis
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t for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions.
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Home O2 is not a requirement unless the patient's oxygenation saturation is below normal.
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12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will veri
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fy that which of the following physician orders have been completed before administering a dose
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of cefotetan (Cefotan) to the patient?
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A. Serum laboratory studies ordered for AM
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B. Pulmonary function evaluation
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C. Orthostatic blood pressures
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D. Sputum culture and sensitivity - CORRECT ANSWER-
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D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture and sensitivi
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ty was sent to the laboratory before administering the cefotetan. It is important that the organism
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s are correctly identified (by the culture) before their numbers are affected by the antibiotic; the t
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est will also determine whether the proper antibiotic has been ordered (sensitivity testing). Althou
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gh antibiotic administration should not be unduly delayed while waiting for the patient to expector
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ate sputum, all of the other options will not be affected by the administration of antibiotics.
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13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
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patient with unilateral malignant lung disease?
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A. Positioning patient on right side.
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B. Maintaining adequate fluid intake
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C. Performing postural drainage every 4 hours
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D. Positioning patient with "good lung down" - CORRECT ANSWER-
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D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position f
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or the patient assuring stable oxygenation status. Research indicates that positioning the patient w
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ith the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilater
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al lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. I
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ncreasing fluid intake and performing postural drainage will facilitate airway clearance, but positio
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ning is most appropriate to enhance oxygenation.
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14. A 71-year-
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old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the follo
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wing nursing interventions is most appropriate during admission of this patient?
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A. Delay any physical assessment of the patient and review with the family the patient's history of
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respiratory problems. B. Perform a comprehensive health history with the patient to review prior r
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espiratory problems. QW
C. Perform a physical assessment of the respiratory system and ask specific questions related to th
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is episode of respiratory distress.
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D. Complete a full physical examination to determine the effect of the respiratory distress on othe
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r body functions. - CORRECT ANSWER-
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C. Perform a physical assessment of the respiratory system and ask specific questions related to th
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QUESTIONS AND ANSWERS |
ALREADY PASSED | 2025 LATEST!!
The nurse assesses a patient with shortness of breath for evidence of long-
QW QW QW QW QW QW QW QW QW QW QW QW
standing hypoxemia by inspecting: QW QW QW
A. Chest excursion
QW QW
B. Spinal curvatures
QW QW
C. The respiratory pattern
QW QW QW
D. The fingernail and its base - CORRECT ANSWER-
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D. The fingernail and its base Clubbing, a sign of long-
QW QW QW QW QW QW QW QW QW QW
standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the
QW QW QW QW QW QW QW QW QW QW QW QW QW QW QW QW QW Q
fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and spo
W QW QW QW QW QW QW QW QW QW QW QW QW QW QW QW QW
nginess of the end of the finger.QW QW QW QW QW QW
2. The nurse is caring for a patient with COPD and pneumonia who has an order for arterial blood
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gases to be drawn. Which of the following is the minimum length of time the nurse should plan to
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hold pressure on the puncture site?
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A. 2 minutes
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B. 5 minutes
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C. 10 minutes
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D. 15 minutes - CORRECT ANSWER-
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B. 5 minutes Following obtaining an arterial blood gas, the nurse should hold pressure on the punc
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ture site for 5 minutes by the clock to be sure that bleeding has stopped. An artery is an elastic ve
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ssel under higher pressure than veins, and significant blood loss or hematoma formation could occ
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ur if the time is insufficient.
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3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including
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a nasal fracture. The nurse should:
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A. test the drainage for the presence of glucose.
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B. suction the nose to maintain airway clearance.
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C. document the findings and continue monitoring.
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D. apply a drip pad and reassure the patient this is normal. - CORRECT ANSWER-
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A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebros
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pinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate t
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he presence of CSF.
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,4. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priorit
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y assessment would be:
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A. Airway patency
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B. Patient comfort
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C. Incisional drainage
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D. Blood pressure and heart rate - CORRECT ANSWER-
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A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priorit
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y and is essential for a patient undergoing surgery surrounding the upper respiratory system.
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5. When initially teaching a patient the supraglottic swallow following a radical neck dissection, wit
QW QW QW QW QW QW QW QW QW QW QW QW QW QW
h which of the following foods should the nurse begin?
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A. Cola QW
B. Applesauce
QW
C. French fries
QW QW
D. White grape juice - CORRECT ANSWER-
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A. ColaWhen learning the supraglottic swallow, it may be helpful to start with carbonated beverag
QW QW QW QW QW QW QW QW QW QW QW QW QW QW
es because the effervescence provides clues about the liquid's position. Thin, watery fluids should
QW QW QW QW QW QW QW QW QW QW QW QW QW QW
be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable p
QW QW QW QW QW QW QW QW QW QW QW QW QW QW QW
ureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages
QW QW QW QW QW QW QW QW QW QW QW QW QW QW
are the better choice to start with.
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6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, th
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e nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory
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rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessme
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nt? A. Hyperthermia related to infectious illness
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B. Ineffective thermoregulation related to chilling
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C. Ineffective breathing pattern related to pneumonia
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D. Ineffective airway clearance related to thick secretions - CORRECT ANSWER-
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A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has
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a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illnes
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s. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths p
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er minute. There is no evidence of ineffective airway clearance from the information given becaus
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e the patient is expectorating sputum.
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7. Which of the following physical assessment findings in a patient with pneumonia best supports t
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he nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
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B. Respiratory rate of 28
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C. Presence of greenish sputum
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D. Basilar crackles - CORRECT ANSWER-
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D. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation
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,Wof secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective
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Wairway clearance because the patient is retaining secretions.
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8. Which of the following clinical manifestations would the nurse expect to find during assessment
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of a patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
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B. Fine crackles in all lobes on auscultation
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C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -
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CORRECT ANSWER-
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C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with p
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neumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include
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dullness to percussion, bronchial breath sounds, and crackles in the affected area.
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9. Which of the following nursing interventions is of the highest priority in helping a patient expect
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orate thick secretions related to pneumonia?
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A. Humidify the oxygen as able
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B. Increase fluid intake to 3L/day if tolerated.
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C. Administer cough suppressant q4hr.
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D. Teach patient to splint the affected area. - CORRECT ANSWER-
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B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient
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expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the
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secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also he
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lpful, but is not the primary intervention. Teaching the patient to splint the affected area may also
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be helpful, but does not liquefy the secretions so that they can be removed.
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10. During discharge teaching for a 65-year-
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old patient with emphysema and pneumonia, which of the following vaccines should the nurse rec
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ommend the patient receive? QW QW QW
A. S. aureus
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B. H. influenzae
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C. Pneumococcal
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D. Bacille Calmette-Guérin (BCG) - CORRECT ANSWER-
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C. Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lun
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g disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.
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11. The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has bee
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n most effective when the patient states which of the following measures to prevent a relapse?
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A. "I will increase my food intake to 2400 calories a day to keep my immune system well."
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B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."
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C. "I will seek immediate medical treatment for any upper respiratory infections."
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D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." -
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CORRECT ANSWER-D. "I should continue to do deep-
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breathing and coughing exercises for at least 6 weeks." It is important for the patient to continue
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, with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared f
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rom the lungs. A patient should seek medical treatment for upper respiratory infections that persis
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t for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions.
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Home O2 is not a requirement unless the patient's oxygenation saturation is below normal.
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12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will veri
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fy that which of the following physician orders have been completed before administering a dose
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of cefotetan (Cefotan) to the patient?
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A. Serum laboratory studies ordered for AM
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B. Pulmonary function evaluation
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C. Orthostatic blood pressures
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D. Sputum culture and sensitivity - CORRECT ANSWER-
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D. Sputum culture and sensitivityThe nurse should ensure that the sputum for culture and sensitivi
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ty was sent to the laboratory before administering the cefotetan. It is important that the organism
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s are correctly identified (by the culture) before their numbers are affected by the antibiotic; the t
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est will also determine whether the proper antibiotic has been ordered (sensitivity testing). Althou
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gh antibiotic administration should not be unduly delayed while waiting for the patient to expector
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ate sputum, all of the other options will not be affected by the administration of antibiotics.
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13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
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patient with unilateral malignant lung disease?
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A. Positioning patient on right side.
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B. Maintaining adequate fluid intake
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C. Performing postural drainage every 4 hours
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D. Positioning patient with "good lung down" - CORRECT ANSWER-
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D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position f
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or the patient assuring stable oxygenation status. Research indicates that positioning the patient w
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ith the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilater
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al lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. I
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ncreasing fluid intake and performing postural drainage will facilitate airway clearance, but positio
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ning is most appropriate to enhance oxygenation.
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14. A 71-year-
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old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the follo
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wing nursing interventions is most appropriate during admission of this patient?
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A. Delay any physical assessment of the patient and review with the family the patient's history of
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respiratory problems. B. Perform a comprehensive health history with the patient to review prior r
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espiratory problems. QW
C. Perform a physical assessment of the respiratory system and ask specific questions related to th
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is episode of respiratory distress.
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D. Complete a full physical examination to determine the effect of the respiratory distress on othe
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r body functions. - CORRECT ANSWER-
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C. Perform a physical assessment of the respiratory system and ask specific questions related to th
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