Latest Red HESI Med Surg Exam 2025 | bb bb bb bb b b bb bb
Q&A with Well-Elaborated Rationales
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The nurse assesses a patient with shortness of breath for evidence of long-standing
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hypoxemia by inspecting:
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A. Chest excursion bb
B. Spinal curvatures bb
C. The respiratory pattern bb bb
D. The fingernail and its base - ✓✓-D. The fingernail and its base Clubbing, a sign of
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
long-standing hypoxemia, is evidenced by an increase in the angle between the base
bb bb bb bb bb bb bb bb bb bb bb bb bb
of the nail and the fingernail to 180 degrees or more, usually accompanied by an
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
increase in the depth, bulk, and sponginess of the end of the finger.
bb bb bb bb bb bb bb bb bb bb bb bb bb
2. The nurse is caring for a patient with COPD and pneumonia who has an order
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
for arterial blood gases to be drawn. Which of the following is the minimum length of
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
time the nurse should plan to hold pressure on the puncture site?
bb bb bb bb bb bb bb bb bb bb bb bb
A. 2 minutes bb
B. 5 minutes bb
C. 10 minutes bb
D. 15 minutes - ✓✓-B. 5 minutes Following obtaining an arterial blood gas, the
bb bb bb bb bb bb bb bb bb bb bb bb
nurse should hold pressure on the puncture site for 5 minutes by the clock to be
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
sure that bleeding has stopped. An artery is an elastic vessel under higher pressure
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
than veins, and significant blood loss or hematoma formation could occur if the time
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
is insufficient.
bb bb
3. The nurse notices clear nasal drainage in a patient newly admitted with facial
bb bb bb bb bb bb bb bb bb bb bb bb
trauma, including a nasal fracture. The nurse should:
bb bb bb bb bb bb bb bb
A. test the drainage for the presence of glucose.
bb bb bb bb bb bb bb
B. suction the nose to maintain airway clearance. bb bb bb bb bb bb
C. document the findings and continue monitoring. bb bb bb bb bb
D. apply a drip pad and reassure the patient this is normal. - ✓✓-A. test the drainage
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
, for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal
bb bb bb bb bb bb bb bb bb bb bb bb
fluid (CSF). The drainage should be tested for the presence of glucose, which would
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
indicate the presence of CSF.
bb bb bb bb bb
4. When caring for a patient who is 3 hours postoperative laryngectomy, the
bb bb bb bb bb bb bb bb bb bb bb
nurse's highest priority assessment would be:
bb bb bb bb bb bb
A. Airway patency bb
B. Patient comfort bb
,C. Incisional drainage bb
D. Blood pressure and heart rate - ✓✓-A. Airway patency Remember ABCs with
bb bb bb bb bb bb bb bb bb bb bb
prioritization. Airway patency is always the highest priority and is essential for a
bb bb bb bb bb bb bb bb bb bb bb bb bb
patient undergoing surgery surrounding the upper respiratory system.
bb bb bb bb bb bb bb bb
5. When initially teaching a patient the supraglottic swallow following a radical
bb bb bb bb bb bb bb bb bb bb
neck dissection, with which of the following foods should the nurse begin?
bb bb bb bb bb bb bb bb bb bb bb bb
A. Cola
B. Applesauce
C. French fries bb
D. White grape juice - ✓✓-A. Cola When learning the supraglottic swallow, it may be
bb bb bb bb bb bb bb bb bb bb bb bb bb
helpful to start with carbonated beverages because the effervescence provides clues
bb bb bb bb bb bb bb bb bb bb bb
about the liquid's position. Thin, watery fluids should be avoided because they are
bb bb bb bb bb bb bb bb bb bb bb bb bb
difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods,
bb bb bb bb bb bb bb bb bb bb bb bb
such as applesauce, would decrease the risk of aspiration, but carbonated beverages
bb bb bb bb bb bb bb bb bb bb bb bb
are the better choice to start with.
bb bb bb bb bb bb bb
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon
bb bb bb bb bb bb bb bb bb bb bb bb bb
assessment, the nurse notes a temperature of 101.4° F, a productive cough with
bb bb bb bb bb bb bb bb bb bb bb bb bb
yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
is most appropriate based upon this assessment? A. Hyperthermia related to
bb bb bb bb bb bb bb bb bb bb bb
infectious illness
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B. Ineffective thermoregulation related to chilling
bb bb bb bb bb
C. Ineffective breathing pattern related to pneumonia
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D. Ineffective airway clearance related to thick secretions - ✓✓-A. Hyperthermia related
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to infectious illness Because the patient has spiked a temperature and has a
bb bb bb bb bb bb bb bb bb bb bb bb bb
diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to
bb bb bb bb bb bb bb bb bb bb bb
infectious illness. There is no evidence of a chill, and her breathing pattern is within
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
normal limits at 20 breaths per minute. There is no evidence of ineffective airway
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
clearance from the information given because the patient is expectorating sputum.
bb bb bb bb bb bb bb bb bb bb bb
7. Which of the following physical assessment findings in a patient with pneumonia best
bb bb bb bb bb bb bb bb bb bb bb bb
supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation
bb bb bb bb bb bb bb bb bb bb bb
of 85%
bb bb
B. Respiratory rate of 28
bb bb bb bb
C. Presence of greenish sputum
bb bb bb bb
D. Basilar crackles - ✓✓-D. Basilar crackles The presence of adventitious breath
bb bb bb bb bb bb bb bb bb bb bb
sounds indicates that there is accumulation of secretions in the lower airways. This
bb bb bb bb bb bb bb bb bb bb bb bb bb
would be consistent with a nursing diagnosis of ineffective airway clearance because
bb bb bb bb bb bb bb bb bb bb bb bb
the patient is retaining secretions.
bb bb bb bb bb
, 8. Which of the following clinical manifestations would the nurse expect to find
bb bb bb bb bb bb bb bb bb bb bb
during assessment of a patient admitted with pneumococcal pneumonia? A.
bb bb bb bb bb bb bb bb bb bb
Hyperresonance on percussion
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B. Fine crackles in all lobes on auscultation
bb bb bb bb bb bb bb
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - ✓✓-
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
C. Increased vocal fremitus on palpation. A typical physical examination finding for a
bb bb bb bb bb bb bb bb bb bb bb bb
patient with pneumonia is increased vocal fremitus on palpation. Other signs of
bb bb bb bb bb bb bb bb bb bb bb bb
pulmonary consolidation include dullness to percussion, bronchial breath sounds, and
bb bb bb bb bb bb bb bb bb bb
crackles in the affected area.
bb bb bb bb bb
9. Which of the following nursing interventions is of the highest priority in helping
bb bb bb bb bb bb bb bb bb bb bb bb
a patient expectorate thick secretions related to pneumonia?
bb bb bb bb bb bb bb bb
A. Humidify the oxygen as able bb bb bb bb
B. Increase fluid intake to 3L/day if tolerated. bb bb bb bb bb bb
C. Administer cough suppressant q4hr. bb bb bb
D. Teach patient to splint the affected area. - ✓✓-B. Increase fluid intake to 3L/day if
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
tolerated. Although several interventions may help the patient expectorate mucus,
bb bb bb bb bb bb bb bb bb bb
the highest priority should be on increasing fluid intake, which will liquefy the
bb bb bb bb bb bb bb bb bb bb bb bb bb
secretions so that the patient can expectorate them more easily. Humidifying the
bb bb bb bb bb bb bb bb bb bb bb bb
oxygen is also helpful, but is not the primary intervention. Teaching the patient to
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
splint the affected area may also be helpful, but does not liquefy the secretions so
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
that they can be removed.
bb bb bb bb bb
10. During discharge teaching for a 65-year-old patient with emphysema and
bb bb bb bb bb bb bb bb bb
pneumonia, which of the following vaccines should the nurse recommend the
bb bb bb bb bb bb bb bb bb bb bb
patient receive?
bb bb
A. S. aureus bb
B. H. influenzae bb
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - ✓✓-C. Pneumococcal The pneumococcal vaccine is
bb bb bb bb bb bb bb bb bb
important for patients with a history of heart or lung disease, recovering from a
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
severe illness, age 65 or over, or living in a long-term care facility.
bb bb bb bb bb bb bb bb bb bb bb bb bb
11. The nurse evaluates that discharge teaching for a patient hospitalized with
bb bb bb bb bb bb bb bb bb bb
pneumonia has been most effective when the patient states which of the
bb bb bb bb bb bb bb bb bb bb bb bb
following measures to prevent a relapse?
bb bb bb bb bb bb
A. "I will increase my food intake to 2400 calories a day to keep my immune
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
system well."
bb bb
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
to reevaluate."
bb bb
Q&A with Well-Elaborated Rationales
bb bb bb bb
The nurse assesses a patient with shortness of breath for evidence of long-standing
bb bb bb bb bb bb bb bb bb bb bb bb
hypoxemia by inspecting:
bb bb bb
A. Chest excursion bb
B. Spinal curvatures bb
C. The respiratory pattern bb bb
D. The fingernail and its base - ✓✓-D. The fingernail and its base Clubbing, a sign of
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
long-standing hypoxemia, is evidenced by an increase in the angle between the base
bb bb bb bb bb bb bb bb bb bb bb bb bb
of the nail and the fingernail to 180 degrees or more, usually accompanied by an
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
increase in the depth, bulk, and sponginess of the end of the finger.
bb bb bb bb bb bb bb bb bb bb bb bb bb
2. The nurse is caring for a patient with COPD and pneumonia who has an order
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
for arterial blood gases to be drawn. Which of the following is the minimum length of
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
time the nurse should plan to hold pressure on the puncture site?
bb bb bb bb bb bb bb bb bb bb bb bb
A. 2 minutes bb
B. 5 minutes bb
C. 10 minutes bb
D. 15 minutes - ✓✓-B. 5 minutes Following obtaining an arterial blood gas, the
bb bb bb bb bb bb bb bb bb bb bb bb
nurse should hold pressure on the puncture site for 5 minutes by the clock to be
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
sure that bleeding has stopped. An artery is an elastic vessel under higher pressure
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
than veins, and significant blood loss or hematoma formation could occur if the time
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
is insufficient.
bb bb
3. The nurse notices clear nasal drainage in a patient newly admitted with facial
bb bb bb bb bb bb bb bb bb bb bb bb
trauma, including a nasal fracture. The nurse should:
bb bb bb bb bb bb bb bb
A. test the drainage for the presence of glucose.
bb bb bb bb bb bb bb
B. suction the nose to maintain airway clearance. bb bb bb bb bb bb
C. document the findings and continue monitoring. bb bb bb bb bb
D. apply a drip pad and reassure the patient this is normal. - ✓✓-A. test the drainage
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
, for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal
bb bb bb bb bb bb bb bb bb bb bb bb
fluid (CSF). The drainage should be tested for the presence of glucose, which would
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
indicate the presence of CSF.
bb bb bb bb bb
4. When caring for a patient who is 3 hours postoperative laryngectomy, the
bb bb bb bb bb bb bb bb bb bb bb
nurse's highest priority assessment would be:
bb bb bb bb bb bb
A. Airway patency bb
B. Patient comfort bb
,C. Incisional drainage bb
D. Blood pressure and heart rate - ✓✓-A. Airway patency Remember ABCs with
bb bb bb bb bb bb bb bb bb bb bb
prioritization. Airway patency is always the highest priority and is essential for a
bb bb bb bb bb bb bb bb bb bb bb bb bb
patient undergoing surgery surrounding the upper respiratory system.
bb bb bb bb bb bb bb bb
5. When initially teaching a patient the supraglottic swallow following a radical
bb bb bb bb bb bb bb bb bb bb
neck dissection, with which of the following foods should the nurse begin?
bb bb bb bb bb bb bb bb bb bb bb bb
A. Cola
B. Applesauce
C. French fries bb
D. White grape juice - ✓✓-A. Cola When learning the supraglottic swallow, it may be
bb bb bb bb bb bb bb bb bb bb bb bb bb
helpful to start with carbonated beverages because the effervescence provides clues
bb bb bb bb bb bb bb bb bb bb bb
about the liquid's position. Thin, watery fluids should be avoided because they are
bb bb bb bb bb bb bb bb bb bb bb bb bb
difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods,
bb bb bb bb bb bb bb bb bb bb bb bb
such as applesauce, would decrease the risk of aspiration, but carbonated beverages
bb bb bb bb bb bb bb bb bb bb bb bb
are the better choice to start with.
bb bb bb bb bb bb bb
6. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon
bb bb bb bb bb bb bb bb bb bb bb bb bb
assessment, the nurse notes a temperature of 101.4° F, a productive cough with
bb bb bb bb bb bb bb bb bb bb bb bb bb
yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
is most appropriate based upon this assessment? A. Hyperthermia related to
bb bb bb bb bb bb bb bb bb bb bb
infectious illness
bb bb
B. Ineffective thermoregulation related to chilling
bb bb bb bb bb
C. Ineffective breathing pattern related to pneumonia
bb bb bb bb bb bb
D. Ineffective airway clearance related to thick secretions - ✓✓-A. Hyperthermia related
bb bb bb bb bb bb bb bb bb bb bb
to infectious illness Because the patient has spiked a temperature and has a
bb bb bb bb bb bb bb bb bb bb bb bb bb
diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to
bb bb bb bb bb bb bb bb bb bb bb
infectious illness. There is no evidence of a chill, and her breathing pattern is within
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
normal limits at 20 breaths per minute. There is no evidence of ineffective airway
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
clearance from the information given because the patient is expectorating sputum.
bb bb bb bb bb bb bb bb bb bb bb
7. Which of the following physical assessment findings in a patient with pneumonia best
bb bb bb bb bb bb bb bb bb bb bb bb
supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation
bb bb bb bb bb bb bb bb bb bb bb
of 85%
bb bb
B. Respiratory rate of 28
bb bb bb bb
C. Presence of greenish sputum
bb bb bb bb
D. Basilar crackles - ✓✓-D. Basilar crackles The presence of adventitious breath
bb bb bb bb bb bb bb bb bb bb bb
sounds indicates that there is accumulation of secretions in the lower airways. This
bb bb bb bb bb bb bb bb bb bb bb bb bb
would be consistent with a nursing diagnosis of ineffective airway clearance because
bb bb bb bb bb bb bb bb bb bb bb bb
the patient is retaining secretions.
bb bb bb bb bb
, 8. Which of the following clinical manifestations would the nurse expect to find
bb bb bb bb bb bb bb bb bb bb bb
during assessment of a patient admitted with pneumococcal pneumonia? A.
bb bb bb bb bb bb bb bb bb bb
Hyperresonance on percussion
bb bb bb
B. Fine crackles in all lobes on auscultation
bb bb bb bb bb bb bb
C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes - ✓✓-
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
C. Increased vocal fremitus on palpation. A typical physical examination finding for a
bb bb bb bb bb bb bb bb bb bb bb bb
patient with pneumonia is increased vocal fremitus on palpation. Other signs of
bb bb bb bb bb bb bb bb bb bb bb bb
pulmonary consolidation include dullness to percussion, bronchial breath sounds, and
bb bb bb bb bb bb bb bb bb bb
crackles in the affected area.
bb bb bb bb bb
9. Which of the following nursing interventions is of the highest priority in helping
bb bb bb bb bb bb bb bb bb bb bb bb
a patient expectorate thick secretions related to pneumonia?
bb bb bb bb bb bb bb bb
A. Humidify the oxygen as able bb bb bb bb
B. Increase fluid intake to 3L/day if tolerated. bb bb bb bb bb bb
C. Administer cough suppressant q4hr. bb bb bb
D. Teach patient to splint the affected area. - ✓✓-B. Increase fluid intake to 3L/day if
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
tolerated. Although several interventions may help the patient expectorate mucus,
bb bb bb bb bb bb bb bb bb bb
the highest priority should be on increasing fluid intake, which will liquefy the
bb bb bb bb bb bb bb bb bb bb bb bb bb
secretions so that the patient can expectorate them more easily. Humidifying the
bb bb bb bb bb bb bb bb bb bb bb bb
oxygen is also helpful, but is not the primary intervention. Teaching the patient to
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
splint the affected area may also be helpful, but does not liquefy the secretions so
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
that they can be removed.
bb bb bb bb bb
10. During discharge teaching for a 65-year-old patient with emphysema and
bb bb bb bb bb bb bb bb bb
pneumonia, which of the following vaccines should the nurse recommend the
bb bb bb bb bb bb bb bb bb bb bb
patient receive?
bb bb
A. S. aureus bb
B. H. influenzae bb
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - ✓✓-C. Pneumococcal The pneumococcal vaccine is
bb bb bb bb bb bb bb bb bb
important for patients with a history of heart or lung disease, recovering from a
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
severe illness, age 65 or over, or living in a long-term care facility.
bb bb bb bb bb bb bb bb bb bb bb bb bb
11. The nurse evaluates that discharge teaching for a patient hospitalized with
bb bb bb bb bb bb bb bb bb bb
pneumonia has been most effective when the patient states which of the
bb bb bb bb bb bb bb bb bb bb bb bb
following measures to prevent a relapse?
bb bb bb bb bb bb
A. "I will increase my food intake to 2400 calories a day to keep my immune
bb bb bb bb bb bb bb bb bb bb bb bb bb bb
system well."
bb bb
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray
bb bb bb bb bb bb bb bb bb bb bb bb bb bb bb
to reevaluate."
bb bb
