Page |1
Med Surg Test bank ( Red HESI Test bank
Med-Surg and other resources) Questions
and Correct Answers/ Latest Update /
Already Graded
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
Ans: 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
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C. 10 minutes
D. 15 minutes
Ans: 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.
Ans: 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:
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A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
Ans: 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
Ans: 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
All rights reserved © 2025/ 2026 |
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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
Ans: 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
All rights reserved © 2025/ 2026 |
Med Surg Test bank ( Red HESI Test bank
Med-Surg and other resources) Questions
and Correct Answers/ Latest Update /
Already Graded
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
Ans: 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
All rights reserved © 2025/ 2026 |
, Page |2
C. 10 minutes
D. 15 minutes
Ans: 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.
Ans: 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:
All rights reserved © 2025/ 2026 |
, Page |3
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
Ans: 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
Ans: 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
All rights reserved © 2025/ 2026 |
, Page |4
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
Ans: 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
All rights reserved © 2025/ 2026 |
