HESI RN: Med-Surg EXIT EXAM / MED
SURG HESI PN LATEST EXAM 2026-2027
ACTUAL EXAM TEST BANK 1 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 AnswerA.
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
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,breaths per minute. There is no evidence of ineffective airway clearance from the
information given because the patient is expectorating sputum.
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 crackle - Correct AnswerD. Basilar crackles
The presence of adventitious breath sounds indicates that there is an
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.
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
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,D. Vesicular breath sounds in all lobes - Correct AnswerC. 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.
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. - Correct AnswerB. Increase fluid
intake to 3L/day if tolerated. Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing fluid intake, which
will liquefy the secretions so that the patient can expectorate them more easily.
Humidifying the oxygen is also helpful, but is not the primary intervention.
Teaching the patient to splint the affected area may also be helpful, but does not
liquefy the secretions so that they can be removed.
During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the
patient receive?
A. S. aureus
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, B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - Correct AnswerC. Pneumococcal The
pneumococcal vaccine is important for patients with a history of heart or lung
disease, recovering from a severe illness, age 65 or over, or living in a long-term
care facility.
The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the
following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune
system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray
to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - Correct AnswerD. "I should continue to do deep-breathing and coughing
exercises for at least 6 weeks." It is important for the patient to continue with
coughing and deep breathing exercises for 6 to 8 weeks until all of the infection
has cleared from the lungs. A patient should seek medical treatment for upper
respiratory infections that persist for more than 7 days. Increased fluid intake, not
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SURG HESI PN LATEST EXAM 2026-2027
ACTUAL EXAM TEST BANK 1 QUESTIONS
AND CORRECT DETAILED ANSWERS
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 AnswerA.
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
Page 1 of 191
,breaths per minute. There is no evidence of ineffective airway clearance from the
information given because the patient is expectorating sputum.
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 crackle - Correct AnswerD. Basilar crackles
The presence of adventitious breath sounds indicates that there is an
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.
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
Page 2 of 191
,D. Vesicular breath sounds in all lobes - Correct AnswerC. 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.
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. - Correct AnswerB. Increase fluid
intake to 3L/day if tolerated. Although several interventions may help the patient
expectorate mucus, the highest priority should be on increasing fluid intake, which
will liquefy the secretions so that the patient can expectorate them more easily.
Humidifying the oxygen is also helpful, but is not the primary intervention.
Teaching the patient to splint the affected area may also be helpful, but does not
liquefy the secretions so that they can be removed.
During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the
patient receive?
A. S. aureus
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, B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - Correct AnswerC. Pneumococcal The
pneumococcal vaccine is important for patients with a history of heart or lung
disease, recovering from a severe illness, age 65 or over, or living in a long-term
care facility.
The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the
following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune
system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray
to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - Correct AnswerD. "I should continue to do deep-breathing and coughing
exercises for at least 6 weeks." It is important for the patient to continue with
coughing and deep breathing exercises for 6 to 8 weeks until all of the infection
has cleared from the lungs. A patient should seek medical treatment for upper
respiratory infections that persist for more than 7 days. Increased fluid intake, not
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