MED SURG II HESI TEST BANK – 100+
Questions with Correct Answers and
Rationales
**1. The nurse assesses a client 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✔️✔️: Clubbing (increased angle between the nail base and finger) is a classic sign of
chronic hypoxemia . This occurs due to tissue hypertrophy from chronic hypoxia, commonly seen in
conditions like COPD, cystic fibrosis, and congenital heart defects.
**2. A client with COPD and pneumonia has an order for arterial blood gases. What 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✔️✔️: Arterial puncture requires 5 minutes of pressure to prevent bleeding and
hematoma formation . Clients with coagulopathies or on anticoagulants may require longer pressure
application.
**3. Clear nasal drainage in a patient with facial trauma and nasal fracture should prompt the nurse
to:**
A) Test the drainage for glucose
B) Suction the drainage
C) Apply pressure to the nose
D) Pack the nares with gauze
💫ANSWER✔️✔️: A
💫RATIONALE✔️✔️: Clear nasal drainage following facial trauma may indicate cerebrospinal fluid
(CSF) leak. Testing for glucose confirms the presence of CSF, as glucose is not normally found in nasal
secretions .
**4. A client with COPD becomes short of breath while ambulating. Which action should the nurse take
first?**
A) Increase oxygen flow rate
B) Place client in high-Fowler's position
C) Instruct pursed-lip breathing
D) Encourage fluid intake
💫ANSWER✔️✔️: C
, 💫RATIONALE✔️✔️: Pursed-lip breathing prolongs exhalation, reduces air trapping, and relieves
dyspnea quickly . This technique helps COPD patients manage acute shortness of breath by maintaining
airway pressure during expiration.
**5. For thick, tenacious sputum in pneumonia, the most effective intervention to loosen secretions
is:**
A) Limit fluid intake
B) Increase oral fluids
C) Encourage bedrest
D) Offer a low-sodium diet
💫ANSWER✔️✔️: B
💫RATIONALE✔️✔️: Adequate hydration thins respiratory secretions, making them easier to
expectorate . Clients should be encouraged to drink 2-3 liters of fluid daily unless contraindicated by
conditions like heart failure or renal disease.
**6. A client is postoperative following a tracheostomy and has copious, tenacious secretions. An
acceptable method to thin secretions is:**
A) Provide humidified oxygen
B) Perform chest physiotherapy before suctioning
C) Prelubricate the suction catheter tip with sterile saline
D) Hyperventilate with 100% oxygen before suctioning
💫ANSWER✔️✔️: A
💫RATIONALE✔️✔️: Humidified oxygen moistens and loosens thick secretions . Humidity prevents
mucus from drying and becoming tenacious, which can occlude the tracheostomy tube.
Questions with Correct Answers and
Rationales
**1. The nurse assesses a client 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✔️✔️: Clubbing (increased angle between the nail base and finger) is a classic sign of
chronic hypoxemia . This occurs due to tissue hypertrophy from chronic hypoxia, commonly seen in
conditions like COPD, cystic fibrosis, and congenital heart defects.
**2. A client with COPD and pneumonia has an order for arterial blood gases. What 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✔️✔️: Arterial puncture requires 5 minutes of pressure to prevent bleeding and
hematoma formation . Clients with coagulopathies or on anticoagulants may require longer pressure
application.
**3. Clear nasal drainage in a patient with facial trauma and nasal fracture should prompt the nurse
to:**
A) Test the drainage for glucose
B) Suction the drainage
C) Apply pressure to the nose
D) Pack the nares with gauze
💫ANSWER✔️✔️: A
💫RATIONALE✔️✔️: Clear nasal drainage following facial trauma may indicate cerebrospinal fluid
(CSF) leak. Testing for glucose confirms the presence of CSF, as glucose is not normally found in nasal
secretions .
**4. A client with COPD becomes short of breath while ambulating. Which action should the nurse take
first?**
A) Increase oxygen flow rate
B) Place client in high-Fowler's position
C) Instruct pursed-lip breathing
D) Encourage fluid intake
💫ANSWER✔️✔️: C
, 💫RATIONALE✔️✔️: Pursed-lip breathing prolongs exhalation, reduces air trapping, and relieves
dyspnea quickly . This technique helps COPD patients manage acute shortness of breath by maintaining
airway pressure during expiration.
**5. For thick, tenacious sputum in pneumonia, the most effective intervention to loosen secretions
is:**
A) Limit fluid intake
B) Increase oral fluids
C) Encourage bedrest
D) Offer a low-sodium diet
💫ANSWER✔️✔️: B
💫RATIONALE✔️✔️: Adequate hydration thins respiratory secretions, making them easier to
expectorate . Clients should be encouraged to drink 2-3 liters of fluid daily unless contraindicated by
conditions like heart failure or renal disease.
**6. A client is postoperative following a tracheostomy and has copious, tenacious secretions. An
acceptable method to thin secretions is:**
A) Provide humidified oxygen
B) Perform chest physiotherapy before suctioning
C) Prelubricate the suction catheter tip with sterile saline
D) Hyperventilate with 100% oxygen before suctioning
💫ANSWER✔️✔️: A
💫RATIONALE✔️✔️: Humidified oxygen moistens and loosens thick secretions . Humidity prevents
mucus from drying and becoming tenacious, which can occlude the tracheostomy tube.
