HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
D. The fingernail and its base Clubbing,
The nurse assesses a patient with
a sign of long-standing hypoxemia, is
shortness of breath for evidence of
evidenced by an increase in the angle
long-standing hypoxemia by inspecting:
between the base of the nail and the
A. Chest excursion
fingernail to 180 degrees or more, usu-
B. Spinal curvatures
ally accompanied by an increase in the
C. The respiratory pattern
depth, bulk, and sponginess of the end
D.The fingernail and its base
of the finger.
2. The nurse is caring for a patient with
B. 5 minutes Following obtaining an ar-
COPD and pneumonia who has an or-
terial blood gas, the nurse should hold
der for arterial blood gases to be drawn.
pressure on the puncture site for 5 min-
Which of the following is the minimum
utes by the clock to be sure that bleed-
length of time the nurse should plan to
ing has stopped. An artery is an elastic
hold pressure on the puncture site?
vessel under higher pressure than veins,
A. 2 minutes
and significant blood loss or hematoma
B. 5 minutes
formation could occur if the time is insuf-
C. 10 minutes
ficient.
D. 15 minutes
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
A. test the drainage for the presence of glucose. Clear nasal drainage suggests
glucose. leakage of cerebrospinal fluid (CSF).The
B. suction the nose to maintain airway drainage should be tested for the pres-
clearance. ence of glucose, which would indicate
C. document the findings and continue the presence of CSF.
monitoring.
D. apply a drip pad and reassure the
patient this is normal.
4. When caring for a patient who
is 3 hours postoperative laryngectomy,
A. Airway patency Remember ABCs with
the nurse's highest priority assessment
prioritization. Airway patency is always
would be:
the highest priority and is essential for a
A. Airway patency
patient undergoing surgery surrounding
B. Patient comfort
the upper respiratory system.
C. Incisional drainage
D. Blood pressure and heart rate
,HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
A. ColaWhen learning the supraglottic
swallow, it may be helpful to start with
5. When initially teaching a patient the
carbonated beverages because the ef-
supraglottic swallow following a radical
fervescence provides clues about the liq-
neck dissection, with which of the follow-
uid's position. Thin, watery fluids should
ing foods should the nurse begin?
be avoided because they are difficult to
A. Cola
swallow and increase the risk of aspi-
B. Applesauce
C. French fries ration. Nonpourable pureed foods, such
as applesauce, would decrease the risk
D. White grape juice
of aspiration, but carbonated beverages
are the better choice to start with.
6. The nurse is caring for a patient admit-
ted to the hospital with pneumonia. Upon
assessment, the nurse notes a tempera- A. Hyperthermia related to infectious ill-
ture of 101.4° F, a productive cough with ness Because the patient has spiked
yellow sputum and a respiratory rate of a temperature and has a diagnosis of
20. Which of the following nursing diag- pneumonia, the logical nursing diagnosis
nosis is most appropriate based upon is hyperthermia related to infectious ill-
this assessment? A. Hyperthermia relat- ness. There is no evidence of a chill, and
ed to infectious illness her breathing pattern is within normal
B. Ineffective thermoregulation related to limits at 20 breaths per minute. There is
chilling no evidence of ineffective airway clear-
C. Ineffective breathing pattern related to ance from the information given because
pneumonia the patient is expectorating sputum.
D. Ineffective airway clearance related to
thick secretions
7. Which of the following physical as-
D. Basilar crackles The presence of ad-
sessment findings in a patient with pneu-
ventitious breath sounds indicates that
monia best supports the nursing diag-
there is accumulation of secretions in the
nosis of ineffective airway clearance? A.
lower airways. This would be consistent
Oxygen saturation of 85%
with a nursing diagnosis of ineffective
B. Respiratory rate of 28
airway clearance because the patient is
C. Presence of greenish sputum
retaining secretions.
D. Basilar crackles
8. Which of the following clinical mani-
C. Increased vocal fremitus on palpa-
festations would the nurse expect to find
tion. A typical physical examination find-
during assessment of a patient admitted
ing for a patient with pneumonia is in-
with pneumococcal pneumonia? A. Hy-
,HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
perresonance on percussion creased vocal fremitus on palpation. Oth-
B. Fine crackles in all lobes on ausculta- er signs of pulmonary consolidation in-
tion clude dullness to percussion, bronchial
C. Increased vocal fremitus on palpation breath sounds, and crackles in the affect-
D.Vesicular breath sounds in all lobes ed area.
B. Increase fluid intake to 3L/day if toler-
9. Which of the following nursing inter- ated. Although several interventions may
ventions is of the highest priority in help- help the patient expectorate mucus, the
ing a patient expectorate thick secretions highest priority should be on increasing
related to pneumonia? fluid intake, which will liquefy the secre-
A. Humidify the oxygen as able tions so that the patient can expectorate
B. Increase fluid intake to 3L/day if toler- them more easily. Humidifying the oxy-
ated. gen is also helpful, but is not the prima-
C. Administer cough suppressant q4hr. ry intervention. Teaching the patient to
D.Teach patient to splint the affected splint the affected area may also be help-
area. ful, 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 vac- C. Pneumococcal The pneumococcal
cines should the nurse recommend the vaccine is important for patients with a
patient receive? history of heart or lung disease, recover-
A. S. aureus ing from a severe illness, age 65 or over,
B. H. influenzae or living in a long-term care facility.
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. The nurse evaluates that discharge
teaching for a patient hospitalized with D. "I should continue to do deep-breath-
pneumonia has been most effective ing and coughing exercises for at least 6
when the patient states which of the fol- weeks." It is important for the patient to
lowing measures to prevent a relapse? continue with coughing and deep breath-
A. "I will increase my food intake to 2400 ing exercises for 6 to 8 weeks until all of
calories a day to keep my immune sys- the infection has cleared from the lungs.
tem well." A patient should seek medical treatment
B. "I must use home oxygen therapy for 3 for upper respiratory infections that per-
months and then will have a chest x-ray sist for more than 7 days. Increased fluid
to reevaluate." intake, not caloric intake, is required to
C. "I will seek immediate medical treat-
, HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
ment for any upper respiratory infec-
tions." liquefy secretions. Home O2 is not a re-
D. "I should continue to do deep-breath- quirement unless the patient's oxygena-
ing and coughing exercises for at least 6 tion saturation is below normal.
weeks."
D. Sputum culture and sensitivityThe
nurse should ensure that the sputum for
12. After admitting a patient to the med- culture and sensitivity was sent to the
ical unit with a diagnosis of pneumo- laboratory before administering the ce-
nia, the nurse will verify that which of fotetan. It is important that the organisms
the following physician orders have been are correctly identified (by the culture)
completed before administering a dose before their numbers are affected by the
of cefotetan (Cefotan) to the patient? antibiotic; the test will also determine
A. Serum laboratory studies ordered for whether the proper antibiotic has been
AM ordered (sensitivity testing). Although an-
B. Pulmonary function evaluation tibiotic administration should not be un-
C. Orthostatic blood pressures duly delayed while waiting for the patient
D. Sputum culture and sensitivity to expectorate sputum, all of the other
options will not be affected by the admin-
istration of antibiotics.
D. Positioning patient with "good lung
down" Therapeutic positioning identifies
13. Which of the following nursing inter- the best position for the patient assuring
ventions is most appropriate to enhance stable oxygenation status. Research in-
oxygenation in a patient with unilateral dicates that positioning the patient with
malignant lung disease? the unaffected lung (good lung) depen-
A. Positioning patient on right side. dent best promotes oxygenation in pa-
B. Maintaining adequate fluid intake tients with unilateral lung disease. For bi-
C. Performing postural drainage every 4 lateral lung disease, the right lung down
hours has best ventilation and perfusion. In-
D. Positioning patient with "good lung creasing fluid intake and performing pos-
down" tural drainage will facilitate airway clear-
ance, 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 nurs-
ing interventions is most appropriate dur-
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
D. The fingernail and its base Clubbing,
The nurse assesses a patient with
a sign of long-standing hypoxemia, is
shortness of breath for evidence of
evidenced by an increase in the angle
long-standing hypoxemia by inspecting:
between the base of the nail and the
A. Chest excursion
fingernail to 180 degrees or more, usu-
B. Spinal curvatures
ally accompanied by an increase in the
C. The respiratory pattern
depth, bulk, and sponginess of the end
D.The fingernail and its base
of the finger.
2. The nurse is caring for a patient with
B. 5 minutes Following obtaining an ar-
COPD and pneumonia who has an or-
terial blood gas, the nurse should hold
der for arterial blood gases to be drawn.
pressure on the puncture site for 5 min-
Which of the following is the minimum
utes by the clock to be sure that bleed-
length of time the nurse should plan to
ing has stopped. An artery is an elastic
hold pressure on the puncture site?
vessel under higher pressure than veins,
A. 2 minutes
and significant blood loss or hematoma
B. 5 minutes
formation could occur if the time is insuf-
C. 10 minutes
ficient.
D. 15 minutes
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
A. test the drainage for the presence of glucose. Clear nasal drainage suggests
glucose. leakage of cerebrospinal fluid (CSF).The
B. suction the nose to maintain airway drainage should be tested for the pres-
clearance. ence of glucose, which would indicate
C. document the findings and continue the presence of CSF.
monitoring.
D. apply a drip pad and reassure the
patient this is normal.
4. When caring for a patient who
is 3 hours postoperative laryngectomy,
A. Airway patency Remember ABCs with
the nurse's highest priority assessment
prioritization. Airway patency is always
would be:
the highest priority and is essential for a
A. Airway patency
patient undergoing surgery surrounding
B. Patient comfort
the upper respiratory system.
C. Incisional drainage
D. Blood pressure and heart rate
,HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
A. ColaWhen learning the supraglottic
swallow, it may be helpful to start with
5. When initially teaching a patient the
carbonated beverages because the ef-
supraglottic swallow following a radical
fervescence provides clues about the liq-
neck dissection, with which of the follow-
uid's position. Thin, watery fluids should
ing foods should the nurse begin?
be avoided because they are difficult to
A. Cola
swallow and increase the risk of aspi-
B. Applesauce
C. French fries ration. Nonpourable pureed foods, such
as applesauce, would decrease the risk
D. White grape juice
of aspiration, but carbonated beverages
are the better choice to start with.
6. The nurse is caring for a patient admit-
ted to the hospital with pneumonia. Upon
assessment, the nurse notes a tempera- A. Hyperthermia related to infectious ill-
ture of 101.4° F, a productive cough with ness Because the patient has spiked
yellow sputum and a respiratory rate of a temperature and has a diagnosis of
20. Which of the following nursing diag- pneumonia, the logical nursing diagnosis
nosis is most appropriate based upon is hyperthermia related to infectious ill-
this assessment? A. Hyperthermia relat- ness. There is no evidence of a chill, and
ed to infectious illness her breathing pattern is within normal
B. Ineffective thermoregulation related to limits at 20 breaths per minute. There is
chilling no evidence of ineffective airway clear-
C. Ineffective breathing pattern related to ance from the information given because
pneumonia the patient is expectorating sputum.
D. Ineffective airway clearance related to
thick secretions
7. Which of the following physical as-
D. Basilar crackles The presence of ad-
sessment findings in a patient with pneu-
ventitious breath sounds indicates that
monia best supports the nursing diag-
there is accumulation of secretions in the
nosis of ineffective airway clearance? A.
lower airways. This would be consistent
Oxygen saturation of 85%
with a nursing diagnosis of ineffective
B. Respiratory rate of 28
airway clearance because the patient is
C. Presence of greenish sputum
retaining secretions.
D. Basilar crackles
8. Which of the following clinical mani-
C. Increased vocal fremitus on palpa-
festations would the nurse expect to find
tion. A typical physical examination find-
during assessment of a patient admitted
ing for a patient with pneumonia is in-
with pneumococcal pneumonia? A. Hy-
,HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
perresonance on percussion creased vocal fremitus on palpation. Oth-
B. Fine crackles in all lobes on ausculta- er signs of pulmonary consolidation in-
tion clude dullness to percussion, bronchial
C. Increased vocal fremitus on palpation breath sounds, and crackles in the affect-
D.Vesicular breath sounds in all lobes ed area.
B. Increase fluid intake to 3L/day if toler-
9. Which of the following nursing inter- ated. Although several interventions may
ventions is of the highest priority in help- help the patient expectorate mucus, the
ing a patient expectorate thick secretions highest priority should be on increasing
related to pneumonia? fluid intake, which will liquefy the secre-
A. Humidify the oxygen as able tions so that the patient can expectorate
B. Increase fluid intake to 3L/day if toler- them more easily. Humidifying the oxy-
ated. gen is also helpful, but is not the prima-
C. Administer cough suppressant q4hr. ry intervention. Teaching the patient to
D.Teach patient to splint the affected splint the affected area may also be help-
area. ful, 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 vac- C. Pneumococcal The pneumococcal
cines should the nurse recommend the vaccine is important for patients with a
patient receive? history of heart or lung disease, recover-
A. S. aureus ing from a severe illness, age 65 or over,
B. H. influenzae or living in a long-term care facility.
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG)
11. The nurse evaluates that discharge
teaching for a patient hospitalized with D. "I should continue to do deep-breath-
pneumonia has been most effective ing and coughing exercises for at least 6
when the patient states which of the fol- weeks." It is important for the patient to
lowing measures to prevent a relapse? continue with coughing and deep breath-
A. "I will increase my food intake to 2400 ing exercises for 6 to 8 weeks until all of
calories a day to keep my immune sys- the infection has cleared from the lungs.
tem well." A patient should seek medical treatment
B. "I must use home oxygen therapy for 3 for upper respiratory infections that per-
months and then will have a chest x-ray sist for more than 7 days. Increased fluid
to reevaluate." intake, not caloric intake, is required to
C. "I will seek immediate medical treat-
, HESI V1 AND V2 MED SURG QUESTIONS AND ANSWERS EXAM WITH RATIONALES /HES
V1 AND V2 TEST BANK 2025-2026|WELL STRUCTURED|100% PASS
QUESTIONS ANSWERS
ment for any upper respiratory infec-
tions." liquefy secretions. Home O2 is not a re-
D. "I should continue to do deep-breath- quirement unless the patient's oxygena-
ing and coughing exercises for at least 6 tion saturation is below normal.
weeks."
D. Sputum culture and sensitivityThe
nurse should ensure that the sputum for
12. After admitting a patient to the med- culture and sensitivity was sent to the
ical unit with a diagnosis of pneumo- laboratory before administering the ce-
nia, the nurse will verify that which of fotetan. It is important that the organisms
the following physician orders have been are correctly identified (by the culture)
completed before administering a dose before their numbers are affected by the
of cefotetan (Cefotan) to the patient? antibiotic; the test will also determine
A. Serum laboratory studies ordered for whether the proper antibiotic has been
AM ordered (sensitivity testing). Although an-
B. Pulmonary function evaluation tibiotic administration should not be un-
C. Orthostatic blood pressures duly delayed while waiting for the patient
D. Sputum culture and sensitivity to expectorate sputum, all of the other
options will not be affected by the admin-
istration of antibiotics.
D. Positioning patient with "good lung
down" Therapeutic positioning identifies
13. Which of the following nursing inter- the best position for the patient assuring
ventions is most appropriate to enhance stable oxygenation status. Research in-
oxygenation in a patient with unilateral dicates that positioning the patient with
malignant lung disease? the unaffected lung (good lung) depen-
A. Positioning patient on right side. dent best promotes oxygenation in pa-
B. Maintaining adequate fluid intake tients with unilateral lung disease. For bi-
C. Performing postural drainage every 4 lateral lung disease, the right lung down
hours has best ventilation and perfusion. In-
D. Positioning patient with "good lung creasing fluid intake and performing pos-
down" tural drainage will facilitate airway clear-
ance, 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 nurs-
ing interventions is most appropriate dur-
