HESI Med Surg 1
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1. The nurse assesses a patient with D. The fingernail and its base Clubbing, a sign of
shortness of breath for evidence long-standing hypoxemia, is evidenced by an increase
of long-standing hypoxemia by in- in the angle between the base of the nail and the fin-
specting: gernail to 180 degrees or more, usually accompanied
A. Chest excursion by an increase in the depth, bulk, and sponginess of
B. Spinal curvatures the end of the finger.
C. The respiratory pattern
D. The fingernail and its base
2. 2. The nurse is caring for a patient B. 5 minutes Following obtaining an arterial blood
with COPD and pneumonia who has gas, the nurse should hold pressure on the puncture
an order for arterial blood gases to site for 5 minutes by the clock to be sure that bleed-
be drawn. Which of the following ing has stopped. An artery is an elastic vessel under
is the minimum length of time the higher pressure than veins, and significant blood loss
nurse should plan to hold pressure or hematoma formation could occur if the time is
on the puncture site? insufficient.
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
3. 3. The nurse notices clear nasal A. test the drainage for the presence of glucose. Clear
drainage in a patient newly admit- nasal drainage suggests leakage of cerebrospinal flu-
ted with facial trauma, including a id (CSF). The drainage should be tested for the pres-
nasal fracture. The nurse should: ence of glucose, which would indicate the presence of
A. test the drainage for the pres- CSF.
ence of glucose.
B. suction the nose to maintain air-
way clearance.
C. document the findings and con-
tinue monitoring.
, HESI Med Surg 1
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D. apply a drip pad and reassure the
patient this is normal.
4. 4. When caring for a patient who is 3 A. Airway patency Remember ABCs with prioritization.
hours postoperative laryngectomy, Airway patency is always the highest priority and is es-
the nurse's highest priority assess- sential for a patient undergoing surgery surrounding
ment would be: the upper respiratory system.
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
5. 5. When initially teaching a patient A. ColaWhen learning the supraglottic swallow, it may
the supraglottic swallow following a be helpful to start with carbonated beverages because
radical neck dissection, with which the effervescence provides clues about the liquid's
of the following foods should the position. Thin, watery fluids should be avoided be-
nurse begin? cause they are difficult to swallow and increase the
A. Cola risk of aspiration. Nonpourable pureed foods, such as
B. Applesauce applesauce, would decrease the risk of aspiration, but
C. French fries carbonated beverages are the better choice to start
D. White grape juice with.
6. 6. The nurse is caring for a pa- A. Hyperthermia related to infectious illness Because
tient admitted to the hospital with the patient has spiked a temperature and has a diag-
pneumonia. Upon assessment, the nosis of pneumonia, the logical nursing diagnosis is
nurse notes a temperature of hyperthermia related to infectious illness. There is no
101.4° F, a productive cough with evidence of a chill, and her breathing pattern is within
yellow sputum and a respiratory normal limits at 20 breaths per minute. There is no
rate of 20. Which of the following evidence of ineffective airway clearance from the in-
nursing diagnosis is most appropri- formation given because the patient is expectorating
ate based upon this assessment? A. sputum.
Hyperthermia related to infectious
, HESI Med Surg 1
Study online at https://quizlet.com/_2dah9c
illness
B. Ineffective thermoregulation re-
lated to chilling
C. Ineffective breathing pattern re-
lated to pneumonia
D. Ineffective airway clearance re-
lated to thick secretions
7. 7. Which of the following physical D. Basilar crackles The presence of adventitious breath
assessment findings in a patient sounds indicates that there is accumulation of secre-
with pneumonia best supports the tions in the lower airways. This would be consistent
nursing diagnosis of ineffective air- with a nursing diagnosis of ineffective airway clear-
way clearance? A. Oxygen satura- ance because the patient is retaining secretions.
tion of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
8. 8. Which of the following clinical C. Increased vocal fremitus on palpation. A typical
manifestations would the nurse ex- physical examination finding for a patient with pneu-
pect to find during assessment of a monia is increased vocal fremitus on palpation. Other
patient admitted with pneumococ- signs of pulmonary consolidation include dullness to
cal pneumonia? A. Hyperresonance percussion, bronchial breath sounds, and crackles in
on percussion the affected area.
B. Fine crackles in all lobes on aus-
cultation
C. Increased vocal fremitus on pal-
pation D. Vesicular breath sounds in
all lobes
9. 9. Which of the following nursing B. Increase fluid intake to 3L/day if tolerated. Although
interventions is of the highest prior- several interventions may help the patient expectorate
, HESI Med Surg 1
Study online at https://quizlet.com/_2dah9c
ity in helping a patient expectorate mucus, the highest priority should be on increasing
thick secretions related to pneumo- fluid intake, which will liquefy the secretions so that
nia? the patient can expectorate them more easily. Humid-
A. Humidify the oxygen as able ifying the oxygen is also helpful, but is not the primary
B. Increase fluid intake to 3L/day if intervention. Teaching the patient to splint the affected
tolerated. area may also be helpful, but does not liquefy the
C. Administer cough suppressant secretions so that they can be removed.
q4hr.
D. Teach patient to splint the affect-
ed area.
10. 10. During discharge teaching for C. Pneumococcal The pneumococcal vaccine is impor-
a 65-year-old patient with emphy- tant for patients with a history of heart or lung disease,
sema and pneumonia, which of the recovering from a severe illness, age 65 or over, or
following vaccines should the nurse living in a long-term care facility.
recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. 11. The nurse evaluates that dis- D. "I should continue to do deep-breathing and
charge teaching for a patient hos- coughing exercises for at least 6 weeks." It is impor-
pitalized with pneumonia has been tant for the patient to continue with coughing and
most effective when the patient deep breathing exercises for 6 to 8 weeks until all
states which of the following mea- of the infection has cleared from the lungs. A patient
sures to prevent a relapse? should seek medical treatment for upper respiratory
A. "I will increase my food intake infections that persist for more than 7 days. Increased
to 2400 calories a day to keep my fluid intake, not caloric intake, is required to liquefy
immune system well." secretions. Home O2 is not a requirement unless the
B. "I must use home oxygen therapy patient's oxygenation saturation is below normal.
for 3 months and then will have a
Study online at https://quizlet.com/_2dah9c
1. The nurse assesses a patient with D. The fingernail and its base Clubbing, a sign of
shortness of breath for evidence long-standing hypoxemia, is evidenced by an increase
of long-standing hypoxemia by in- in the angle between the base of the nail and the fin-
specting: gernail to 180 degrees or more, usually accompanied
A. Chest excursion by an increase in the depth, bulk, and sponginess of
B. Spinal curvatures the end of the finger.
C. The respiratory pattern
D. The fingernail and its base
2. 2. The nurse is caring for a patient B. 5 minutes Following obtaining an arterial blood
with COPD and pneumonia who has gas, the nurse should hold pressure on the puncture
an order for arterial blood gases to site for 5 minutes by the clock to be sure that bleed-
be drawn. Which of the following ing has stopped. An artery is an elastic vessel under
is the minimum length of time the higher pressure than veins, and significant blood loss
nurse should plan to hold pressure or hematoma formation could occur if the time is
on the puncture site? insufficient.
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
3. 3. The nurse notices clear nasal A. test the drainage for the presence of glucose. Clear
drainage in a patient newly admit- nasal drainage suggests leakage of cerebrospinal flu-
ted with facial trauma, including a id (CSF). The drainage should be tested for the pres-
nasal fracture. The nurse should: ence of glucose, which would indicate the presence of
A. test the drainage for the pres- CSF.
ence of glucose.
B. suction the nose to maintain air-
way clearance.
C. document the findings and con-
tinue monitoring.
, HESI Med Surg 1
Study online at https://quizlet.com/_2dah9c
D. apply a drip pad and reassure the
patient this is normal.
4. 4. When caring for a patient who is 3 A. Airway patency Remember ABCs with prioritization.
hours postoperative laryngectomy, Airway patency is always the highest priority and is es-
the nurse's highest priority assess- sential for a patient undergoing surgery surrounding
ment would be: the upper respiratory system.
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
5. 5. When initially teaching a patient A. ColaWhen learning the supraglottic swallow, it may
the supraglottic swallow following a be helpful to start with carbonated beverages because
radical neck dissection, with which the effervescence provides clues about the liquid's
of the following foods should the position. Thin, watery fluids should be avoided be-
nurse begin? cause they are difficult to swallow and increase the
A. Cola risk of aspiration. Nonpourable pureed foods, such as
B. Applesauce applesauce, would decrease the risk of aspiration, but
C. French fries carbonated beverages are the better choice to start
D. White grape juice with.
6. 6. The nurse is caring for a pa- A. Hyperthermia related to infectious illness Because
tient admitted to the hospital with the patient has spiked a temperature and has a diag-
pneumonia. Upon assessment, the nosis of pneumonia, the logical nursing diagnosis is
nurse notes a temperature of hyperthermia related to infectious illness. There is no
101.4° F, a productive cough with evidence of a chill, and her breathing pattern is within
yellow sputum and a respiratory normal limits at 20 breaths per minute. There is no
rate of 20. Which of the following evidence of ineffective airway clearance from the in-
nursing diagnosis is most appropri- formation given because the patient is expectorating
ate based upon this assessment? A. sputum.
Hyperthermia related to infectious
, HESI Med Surg 1
Study online at https://quizlet.com/_2dah9c
illness
B. Ineffective thermoregulation re-
lated to chilling
C. Ineffective breathing pattern re-
lated to pneumonia
D. Ineffective airway clearance re-
lated to thick secretions
7. 7. Which of the following physical D. Basilar crackles The presence of adventitious breath
assessment findings in a patient sounds indicates that there is accumulation of secre-
with pneumonia best supports the tions in the lower airways. This would be consistent
nursing diagnosis of ineffective air- with a nursing diagnosis of ineffective airway clear-
way clearance? A. Oxygen satura- ance because the patient is retaining secretions.
tion of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D. Basilar crackles
8. 8. Which of the following clinical C. Increased vocal fremitus on palpation. A typical
manifestations would the nurse ex- physical examination finding for a patient with pneu-
pect to find during assessment of a monia is increased vocal fremitus on palpation. Other
patient admitted with pneumococ- signs of pulmonary consolidation include dullness to
cal pneumonia? A. Hyperresonance percussion, bronchial breath sounds, and crackles in
on percussion the affected area.
B. Fine crackles in all lobes on aus-
cultation
C. Increased vocal fremitus on pal-
pation D. Vesicular breath sounds in
all lobes
9. 9. Which of the following nursing B. Increase fluid intake to 3L/day if tolerated. Although
interventions is of the highest prior- several interventions may help the patient expectorate
, HESI Med Surg 1
Study online at https://quizlet.com/_2dah9c
ity in helping a patient expectorate mucus, the highest priority should be on increasing
thick secretions related to pneumo- fluid intake, which will liquefy the secretions so that
nia? the patient can expectorate them more easily. Humid-
A. Humidify the oxygen as able ifying the oxygen is also helpful, but is not the primary
B. Increase fluid intake to 3L/day if intervention. Teaching the patient to splint the affected
tolerated. area may also be helpful, but does not liquefy the
C. Administer cough suppressant secretions so that they can be removed.
q4hr.
D. Teach patient to splint the affect-
ed area.
10. 10. During discharge teaching for C. Pneumococcal The pneumococcal vaccine is impor-
a 65-year-old patient with emphy- tant for patients with a history of heart or lung disease,
sema and pneumonia, which of the recovering from a severe illness, age 65 or over, or
following vaccines should the nurse living in a long-term care facility.
recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. 11. The nurse evaluates that dis- D. "I should continue to do deep-breathing and
charge teaching for a patient hos- coughing exercises for at least 6 weeks." It is impor-
pitalized with pneumonia has been tant for the patient to continue with coughing and
most effective when the patient deep breathing exercises for 6 to 8 weeks until all
states which of the following mea- of the infection has cleared from the lungs. A patient
sures to prevent a relapse? should seek medical treatment for upper respiratory
A. "I will increase my food intake infections that persist for more than 7 days. Increased
to 2400 calories a day to keep my fluid intake, not caloric intake, is required to liquefy
immune system well." secretions. Home O2 is not a requirement unless the
B. "I must use home oxygen therapy patient's oxygenation saturation is below normal.
for 3 months and then will have a
