Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
01The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
inspecting:
D. The fingernail and its base
D. 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.
02. 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?
B. 5 minutes
B. 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.
03. 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.
A. 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.
04. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
A. Airway patency
A. 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.
05. 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
A. 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.
06. 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
A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a
diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no
,Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no
evidence of ineffective airway clearance from the information given because the patient is expectorating
sputum.
07. Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance?
D. Basilar crackles
D. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of
secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway
clearance because the patient is retaining secretions.
08. Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia?
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with pneumonia
is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to
percussion, bronchial breath sounds, and crackles in the affected area.
09. Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia?
B. Increase fluid intake to 3L/day if tolerated.
B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions
so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the
primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not
liquefy the secretions so that they can be removed.
10. 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?
C. Pneumococcal
C. 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.
11. 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?
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
D. "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.
,Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
12. 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?
D. Sputum culture and sensitivity
D. 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.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient
with unilateral malignant lung disease?
D. Positioning patient with "good lung down"
D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position for the
patient assuring stable oxygenation status. Research indicates that positioning the patient with the
unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease.
For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and
performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance
oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the
following nursing interventions is most appropriate during admission of this patient?
C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode
of respiratory distress.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode
of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific
questions about this episode and perform a physical assessment of this system. Further history taking and
physical examination of other body systems can proceed once the patient's acute respiratory distress is being
managed.
15. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-
pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the
patient's underlying respiratory defenses because of impairment of which of the following?
D. Mucociliary clearance
D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in
impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
16. While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation
from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these
findings?
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
, Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An
oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the
exercise and needs to have supplemental oxygen applied.
17. The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third
postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is
wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room
air. Which of the following should the nurse first suspect as the etiology of this episode?
B. Pulmonary embolus from deep vein thrombosis
B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of pulmonary
embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
18. In the case of pulmonary embolus from deep vein thrombosis, which of the following actions should the
nurse take first?
D. Sit the patient up in bed as tolerated and apply oxygen.
D. Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is consistent with
pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the
nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.
19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician
orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the
patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas.
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a
radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the
patient inhales a radioactive gas that outlines the alveoli.
20. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The
nurse interprets that these symptoms are related to which of the following pathophysiologic changes.
Narrowing of the airway
C. Narrowing of the airway Narrowing of the airway leads to reduced airflow, making it difficult for the
patient to breathe and producing the characteristic wheezing.
21. A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of
breath and appears frightened. During the initial nursing assessment, which of the following clinical
manifestations might be present as an early symptom during an exacerbation of asthma?
A. Anxiety
A. Anxiety An early symptom during an asthma attack is anxiety because he is acutely aware of the inability
to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is
hyperventilating.
&correct answers with rationales& explanations
A+ guaranteed
01The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by
inspecting:
D. The fingernail and its base
D. 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.
02. 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?
B. 5 minutes
B. 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.
03. 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.
A. 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.
04. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority
assessment would be:
A. Airway patency
A. 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.
05. 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
A. 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.
06. 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
A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a
diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no
,Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no
evidence of ineffective airway clearance from the information given because the patient is expectorating
sputum.
07. Which of the following physical assessment findings in a patient with pneumonia best supports the
nursing diagnosis of ineffective airway clearance?
D. Basilar crackles
D. Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of
secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway
clearance because the patient is retaining secretions.
08. Which of the following clinical manifestations would the nurse expect to find during assessment of a
patient admitted with pneumococcal pneumonia?
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes
C. Increased vocal fremitus on palpation. A typical physical examination finding for a patient with pneumonia
is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to
percussion, bronchial breath sounds, and crackles in the affected area.
09. Which of the following nursing interventions is of the highest priority in helping a patient expectorate
thick secretions related to pneumonia?
B. Increase fluid intake to 3L/day if tolerated.
B. Increase fluid intake to 3L/day if tolerated. Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions
so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the
primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not
liquefy the secretions so that they can be removed.
10. 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?
C. Pneumococcal
C. 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.
11. 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?
D. "I should continue to do deep-breathing and coughing exercises for at least 6 weeks."
D. "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.
,Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
12. 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?
D. Sputum culture and sensitivity
D. 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.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient
with unilateral malignant lung disease?
D. Positioning patient with "good lung down"
D. Positioning patient with "good lung down" Therapeutic positioning identifies the best position for the
patient assuring stable oxygenation status. Research indicates that positioning the patient with the
unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease.
For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and
performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance
oxygenation.
14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the
following nursing interventions is most appropriate during admission of this patient?
C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode
of respiratory distress.
C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode
of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific
questions about this episode and perform a physical assessment of this system. Further history taking and
physical examination of other body systems can proceed once the patient's acute respiratory distress is being
managed.
15. When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-
pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the
patient's underlying respiratory defenses because of impairment of which of the following?
D. Mucociliary clearance
D. Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in
impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.
16. While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation
from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these
findings?
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity.
, Hesi real medical surgical test bank300 questions
&correct answers with rationales& explanations
A+ guaranteed
C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. An
oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the
exercise and needs to have supplemental oxygen applied.
17. The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third
postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is
wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room
air. Which of the following should the nurse first suspect as the etiology of this episode?
B. Pulmonary embolus from deep vein thrombosis
B. Pulmonary embolus from deep vein thrombosis The patient presents the classic symptoms of pulmonary
embolus: acute onset of symptoms, tachypnea, shortness of breath, and chest pain.
18. In the case of pulmonary embolus from deep vein thrombosis, which of the following actions should the
nurse take first?
D. Sit the patient up in bed as tolerated and apply oxygen.
D. Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is consistent with
pulmonary embolus, and the first action the nurse takes should be to assist the patient. For this reason, the
nurse should sit the patient up as tolerated and apply oxygen before notifying the physician.
19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician
orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the
patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas.
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by
inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a
radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the
patient inhales a radioactive gas that outlines the alveoli.
20. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The
nurse interprets that these symptoms are related to which of the following pathophysiologic changes.
Narrowing of the airway
C. Narrowing of the airway Narrowing of the airway leads to reduced airflow, making it difficult for the
patient to breathe and producing the characteristic wheezing.
21. A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of
breath and appears frightened. During the initial nursing assessment, which of the following clinical
manifestations might be present as an early symptom during an exacerbation of asthma?
A. Anxiety
A. Anxiety An early symptom during an asthma attack is anxiety because he is acutely aware of the inability
to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is
hyperventilating.
