MED-SURG TEST BANK – RED HESI EDITION | MEDICAL-SURGICAL
NURSING 300 QUESTIONS WITH CORRECT ANSWERS & ADDITIONAL
RESOURCES COVERING THE RECENT MOST TESTED QUESTIONS
THE MED-SURG TEST BANK (RED HESI EDITION) PREPARES NURSING STUDENTS
FOR HIGH-STAKES EXAMS BY FOCUSING ON CORE CLINICAL KNOWLEDGE,
PATIENT SAFETY, AND CLINICAL JUDGMENT IN VARIOUS BODY SYSTEMS. THE
QUESTIONS MIRROR THE HESI AND NCLEX FORMATS, SUPPORTING EXAM
SUCCESS THROUGH REALISTIC SCENARIOS AND NURSING APPLICATION.
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 - CORRECT ANSWER-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 - CORRECT 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. - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT
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. - CORRECT 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 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.
10. 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
, B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - CORRECT ANSWER-C. 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.
11. 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 ANSWER-D. "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 caloric intake, is required to liquefy secretions. Home O2 is not a requirement unless the
patient's oxygenation saturation is below normal.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify
that which of the following physician orders have been completed before administering a dose of
cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - CORRECT ANSWER-D. Sputum culture and sensitivityThe
nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before
administering the cefotetan. It is important that the organisms are correctly identified (by the
culture) before their numbers are affected by the antibiotic; the test will also determine whether the
proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should
not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options
will not be affected by the administration of antibiotics.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
NURSING 300 QUESTIONS WITH CORRECT ANSWERS & ADDITIONAL
RESOURCES COVERING THE RECENT MOST TESTED QUESTIONS
THE MED-SURG TEST BANK (RED HESI EDITION) PREPARES NURSING STUDENTS
FOR HIGH-STAKES EXAMS BY FOCUSING ON CORE CLINICAL KNOWLEDGE,
PATIENT SAFETY, AND CLINICAL JUDGMENT IN VARIOUS BODY SYSTEMS. THE
QUESTIONS MIRROR THE HESI AND NCLEX FORMATS, SUPPORTING EXAM
SUCCESS THROUGH REALISTIC SCENARIOS AND NURSING APPLICATION.
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 - CORRECT ANSWER-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 - CORRECT 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. - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT
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. - CORRECT 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 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.
10. 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
, B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - CORRECT ANSWER-C. 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.
11. 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 ANSWER-D. "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 caloric intake, is required to liquefy secretions. Home O2 is not a requirement unless the
patient's oxygenation saturation is below normal.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify
that which of the following physician orders have been completed before administering a dose of
cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - CORRECT ANSWER-D. Sputum culture and sensitivityThe
nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before
administering the cefotetan. It is important that the organisms are correctly identified (by the
culture) before their numbers are affected by the antibiotic; the test will also determine whether the
proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should
not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options
will not be affected by the administration of antibiotics.
13. Which of the following nursing interventions is most appropriate to enhance oxygenation in a
patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
