ADVANCED MED SURG HESI EXAMINATION
TEST 2026 COMPLETE QUESTIONS AND
ANSWERS GRADED A+
● 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.
● 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 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.
● 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 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 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
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.
● 9. 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
TEST 2026 COMPLETE QUESTIONS AND
ANSWERS GRADED A+
● 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.
● 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 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.
● 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 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 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
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.
● 9. 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
