MED SURG HESI V2 EXAM
MED SURG HESI V1 -V7 EXAM REAL
EXAM COMPLETE VERIFIED
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED RATIONALES)
|ALREADY GRADED A+
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 –
Correct Answer :D.
A+ TEST BANK 1
, MED SURG HESI V2 EXAM
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 –
Correct 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. –
Correct 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.
A+ TEST BANK 2
, MED SURG HESI V2 EXAM
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 –
Correct 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.
5. 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
B. Applesauce
C. French fries
D. White grape juice –
Correct Answer :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.
A+ TEST BANK 3
, MED SURG HESI V2 EXAM
6. 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 –
Correct 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.
7. 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 –
Correct 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.
8. 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
A+ TEST BANK 4
MED SURG HESI V1 -V7 EXAM REAL
EXAM COMPLETE VERIFIED
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED RATIONALES)
|ALREADY GRADED A+
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 –
Correct Answer :D.
A+ TEST BANK 1
, MED SURG HESI V2 EXAM
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 –
Correct 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. –
Correct 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.
A+ TEST BANK 2
, MED SURG HESI V2 EXAM
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 –
Correct 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.
5. 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
B. Applesauce
C. French fries
D. White grape juice –
Correct Answer :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.
A+ TEST BANK 3
, MED SURG HESI V2 EXAM
6. 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 –
Correct 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.
7. 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 –
Correct 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.
8. 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
A+ TEST BANK 4
