HESI MED-SURG EXAM BANK/ HESI MED SURG
QUESTION BANK 2025 ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) ALL
ANSWERED {200 Q & A} ALREADY GRADED A+ |
GUARANTEED PASS
1. 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
D. 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
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.
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
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
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
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
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.
QUESTION BANK 2025 ACTUAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) ALL
ANSWERED {200 Q & A} ALREADY GRADED A+ |
GUARANTEED PASS
1. 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
D. 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
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.
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
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
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
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
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.
