MED SURG HESI EXAMS V1 AND V2| MED SURG TEST BANK|
RATIONALES | 2025|26 UPDATE ACTUAL EXAM QUESTIONS WITH
VERIFIED ANSWERS A+ GRADED ||100% GUARANTEED PASS!!
1. The nurse assesses a patient with shortness of breath for evidence of
long-standing hypoxemia by inspecting ANS
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. 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 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. 3. The nurse notices clear nasal drainage in a patient newly admitted with
facial trauma, including a nasal fracture. The nurse should ANS
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. 4. When caring for a patient who is 3 hours postoperative laryngectomy, the
nurse's highest priority assessment would be ANS
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. 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 aspiration, but carbonated
beverages are the better choice to start with.
6. 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. Hy-
perthermia 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 clear-
4 B/ B
168
RATIONALES | 2025|26 UPDATE ACTUAL EXAM QUESTIONS WITH
VERIFIED ANSWERS A+ GRADED ||100% GUARANTEED PASS!!
1. The nurse assesses a patient with shortness of breath for evidence of
long-standing hypoxemia by inspecting ANS
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. 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 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. 3. The nurse notices clear nasal drainage in a patient newly admitted with
facial trauma, including a nasal fracture. The nurse should ANS
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. 4. When caring for a patient who is 3 hours postoperative laryngectomy, the
nurse's highest priority assessment would be ANS
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. 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 aspiration, but carbonated
beverages are the better choice to start with.
6. 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. Hy-
perthermia 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 clear-
4 B/ B
168
