HESI MEDSURG EXAM QUESTIONS WITH 100% CORRECT ANSWERS
. 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
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions - ANSWER-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 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.
. Which of the following physical assessment findings in a patient with pneumonia
best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
,D. Basilar crackles - ANSWER-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.
. Which of the following clinical manifestations would the nurse expect to find
during assessment of a patient admitted with pneumococcal pneumonia? A.
Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -
ANSWER-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.
. Which of the following nursing interventions is of the highest priority in helping a
patient expectorate thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area. - ANSWER-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.
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. 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. 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. 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. 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.
. 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
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions - ANSWER-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 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.
. Which of the following physical assessment findings in a patient with pneumonia
best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
,D. Basilar crackles - ANSWER-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.
. Which of the following clinical manifestations would the nurse expect to find
during assessment of a patient admitted with pneumococcal pneumonia? A.
Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes -
ANSWER-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.
. Which of the following nursing interventions is of the highest priority in helping a
patient expectorate thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area. - ANSWER-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.
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. 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. 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. 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. 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.
