MED SURG TEST BANK ( RED HESI TEST BANK MED-SURG AND OTHER
RESOURCES) EXAM QUESTIONS AND ANSWERS LATEST UPDATE 2025/2026
ALL ANSWERS CORRECT VERIFIED TO SCORE A+ FOR SUCCESS
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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS
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 dof dthe dfollowing dnursing dinterventions dis dof dthe dhighest dpriority din dhelping da
dpatient dexpectorate dthick dsecretions drelated dto dpneumonia? d
A. dHumidify dthe doxygen das dable d
B. dIncrease dfluid dintake dto d3L/day dif dtolerated. d
C. dAdminister dcough dsuppressant dq4hr. d
D. dTeach dpatient dto dsplint dthe daffected darea. d- d dCORRECT dANSWERS d dB. dIncrease dfluid
dintake dto d3L/day dif dtolerated. dAlthough dseveral dinterventions dmay dhelp dthe dpatient
dexpectorate dmucus, dthe dhighest dpriority dshould dbe don dincreasing dfluid dintake, dwhich dwill
dliquefy dthe dsecretions dso dthat dthe dpatient dcan dexpectorate dthem dmore deasily. dHumidifying
dthe doxygen dis dalso dhelpful, dbut dis dnot dthe dprimary dintervention. dTeaching dthe dpatient dto
dsplint dthe daffected darea dmay dalso dbe dhelpful, dbut ddoes dnot dliquefy dthe dsecretions dso dthat
dthey dcan dbe dremoved.
10. dDuring ddischarge dteaching dfor da d65-year-old dpatient dwith demphysema dand dpneumonia,
dwhich dof dthe dfollowing dvaccines dshould dthe dnurse drecommend dthe dpatient dreceive? d
A. dS. daureus d
B. dH. dinfluenzae d
C. dPneumococcal d
D. dBacille dCalmette-Guérin d(BCG) d- d dCORRECT dANSWERS d dC. dPneumococcal dThe
dpneumococcal dvaccine dis dimportant dfor dpatients dwith da dhistory dof dheart dor dlung ddisease,
drecovering dfrom da dsevere dillness, dage d65 dor dover, dor dliving din da dlong-term dcare dfacility.
11. dThe dnurse devaluates dthat ddischarge dteaching dfor da dpatient dhospitalized dwith dpneumonia
dhas dbeen dmost deffective dwhen dthe dpatient dstates dwhich dof dthe dfollowing dmeasures dto
dprevent da drelapse? d
, A. d"I dwill dincrease dmy dfood dintake dto d2400 dcalories da dday dto dkeep dmy dimmune dsystem
dwell." d
B. d"I dmust duse dhome doxygen dtherapy dfor d3 dmonths dand dthen dwill dhave da dchest dx-ray dto
dreevaluate." d
C. d"I dwill dseek dimmediate dmedical dtreatment dfor dany dupper drespiratory dinfections." d
D. d"I dshould dcontinue dto ddo ddeep-breathing dand dcoughing dexercises dfor dat dleast d6 dweeks." d-
d dCORRECT dANSWERS d dD. d"I dshould dcontinue dto ddo ddeep-breathing dand dcoughing dexercises
dfor dat dleast d6 dweeks." dIt dis dimportant dfor dthe dpatient dto dcontinue dwith dcoughing dand ddeep
dbreathing dexercises dfor d6 dto d8 dweeks duntil dall dof dthe dinfection dhas dcleared dfrom dthe dlungs.
dA dpatient dshould dseek dmedical dtreatment dfor dupper drespiratory dinfections dthat dpersist dfor
dmore dthan d7 ddays. dIncreased dfluid dintake, dnot dcaloric dintake, dis drequired dto dliquefy
dsecretions. dHome dO2 dis dnot da drequirement dunless dthe dpatient's doxygenation dsaturation dis
dbelow dnormal.
12. dAfter dadmitting da dpatient dto dthe dmedical dunit dwith da ddiagnosis dof dpneumonia, dthe
dnurse dwill dverify dthat dwhich dof dthe dfollowing dphysician dorders dhave dbeen dcompleted dbefore
dadministering da ddose dof dcefotetan d(Cefotan) dto dthe dpatient? d
A. dSerum dlaboratory dstudies dordered dfor dAM d
B. dPulmonary dfunction devaluation d
C. dOrthostatic dblood dpressures d
D. dSputum dculture dand dsensitivity d- d dCORRECT dANSWERS d dD. dSputum dculture dand
dsensitivityThe dnurse dshould densure dthat dthe dsputum dfor dculture dand dsensitivity dwas dsent dto
dthe dlaboratory dbefore dadministering dthe dcefotetan. dIt dis dimportant dthat dthe dorganisms dare
dcorrectly didentified d(by dthe dculture) dbefore dtheir dnumbers dare daffected dby dthe dantibiotic;
dthe dtest dwill dalso ddetermine dwhether dthe dproper dantibiotic dhas dbeen dordered d(sensitivity
dtesting). dAlthough dantibiotic dadministration dshould dnot dbe dunduly ddelayed dwhile dwaiting dfor
dthe dpatient dto dexpectorate dsputum, dall dof dthe dother doptions dwill dnot dbe daffected dby dthe
dadministration dof dantibiotics.
13. dWhich dof dthe dfollowing dnursing dinterventions dis dmost dappropriate dto denhance
doxygenation din da dpatient dwith dunilateral dmalignant dlung ddisease? d
A. dPositioning dpatient don dright dside. d
B. dMaintaining dadequate dfluid dintake d
C. dPerforming dpostural ddrainage devery d4 dhours d
D. dPositioning dpatient dwith d"good dlung ddown" d- d dCORRECT dANSWERS d dD. dPositioning dpatient
dwith d"good dlung ddown" dTherapeutic dpositioning didentifies dthe dbest dposition dfor dthe dpatient
dassuring dstable doxygenation dstatus. dResearch dindicates dthat dpositioning dthe dpatient dwith dthe
dunaffected dlung d(good dlung) ddependent dbest dpromotes doxygenation din dpatients dwith
dunilateral dlung ddisease. dFor dbilateral dlung ddisease, dthe dright dlung ddown dhas dbest dventilation
RESOURCES) EXAM QUESTIONS AND ANSWERS LATEST UPDATE 2025/2026
ALL ANSWERS CORRECT VERIFIED TO SCORE A+ FOR SUCCESS
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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS
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 dof dthe dfollowing dnursing dinterventions dis dof dthe dhighest dpriority din dhelping da
dpatient dexpectorate dthick dsecretions drelated dto dpneumonia? d
A. dHumidify dthe doxygen das dable d
B. dIncrease dfluid dintake dto d3L/day dif dtolerated. d
C. dAdminister dcough dsuppressant dq4hr. d
D. dTeach dpatient dto dsplint dthe daffected darea. d- d dCORRECT dANSWERS d dB. dIncrease dfluid
dintake dto d3L/day dif dtolerated. dAlthough dseveral dinterventions dmay dhelp dthe dpatient
dexpectorate dmucus, dthe dhighest dpriority dshould dbe don dincreasing dfluid dintake, dwhich dwill
dliquefy dthe dsecretions dso dthat dthe dpatient dcan dexpectorate dthem dmore deasily. dHumidifying
dthe doxygen dis dalso dhelpful, dbut dis dnot dthe dprimary dintervention. dTeaching dthe dpatient dto
dsplint dthe daffected darea dmay dalso dbe dhelpful, dbut ddoes dnot dliquefy dthe dsecretions dso dthat
dthey dcan dbe dremoved.
10. dDuring ddischarge dteaching dfor da d65-year-old dpatient dwith demphysema dand dpneumonia,
dwhich dof dthe dfollowing dvaccines dshould dthe dnurse drecommend dthe dpatient dreceive? d
A. dS. daureus d
B. dH. dinfluenzae d
C. dPneumococcal d
D. dBacille dCalmette-Guérin d(BCG) d- d dCORRECT dANSWERS d dC. dPneumococcal dThe
dpneumococcal dvaccine dis dimportant dfor dpatients dwith da dhistory dof dheart dor dlung ddisease,
drecovering dfrom da dsevere dillness, dage d65 dor dover, dor dliving din da dlong-term dcare dfacility.
11. dThe dnurse devaluates dthat ddischarge dteaching dfor da dpatient dhospitalized dwith dpneumonia
dhas dbeen dmost deffective dwhen dthe dpatient dstates dwhich dof dthe dfollowing dmeasures dto
dprevent da drelapse? d
, A. d"I dwill dincrease dmy dfood dintake dto d2400 dcalories da dday dto dkeep dmy dimmune dsystem
dwell." d
B. d"I dmust duse dhome doxygen dtherapy dfor d3 dmonths dand dthen dwill dhave da dchest dx-ray dto
dreevaluate." d
C. d"I dwill dseek dimmediate dmedical dtreatment dfor dany dupper drespiratory dinfections." d
D. d"I dshould dcontinue dto ddo ddeep-breathing dand dcoughing dexercises dfor dat dleast d6 dweeks." d-
d dCORRECT dANSWERS d dD. d"I dshould dcontinue dto ddo ddeep-breathing dand dcoughing dexercises
dfor dat dleast d6 dweeks." dIt dis dimportant dfor dthe dpatient dto dcontinue dwith dcoughing dand ddeep
dbreathing dexercises dfor d6 dto d8 dweeks duntil dall dof dthe dinfection dhas dcleared dfrom dthe dlungs.
dA dpatient dshould dseek dmedical dtreatment dfor dupper drespiratory dinfections dthat dpersist dfor
dmore dthan d7 ddays. dIncreased dfluid dintake, dnot dcaloric dintake, dis drequired dto dliquefy
dsecretions. dHome dO2 dis dnot da drequirement dunless dthe dpatient's doxygenation dsaturation dis
dbelow dnormal.
12. dAfter dadmitting da dpatient dto dthe dmedical dunit dwith da ddiagnosis dof dpneumonia, dthe
dnurse dwill dverify dthat dwhich dof dthe dfollowing dphysician dorders dhave dbeen dcompleted dbefore
dadministering da ddose dof dcefotetan d(Cefotan) dto dthe dpatient? d
A. dSerum dlaboratory dstudies dordered dfor dAM d
B. dPulmonary dfunction devaluation d
C. dOrthostatic dblood dpressures d
D. dSputum dculture dand dsensitivity d- d dCORRECT dANSWERS d dD. dSputum dculture dand
dsensitivityThe dnurse dshould densure dthat dthe dsputum dfor dculture dand dsensitivity dwas dsent dto
dthe dlaboratory dbefore dadministering dthe dcefotetan. dIt dis dimportant dthat dthe dorganisms dare
dcorrectly didentified d(by dthe dculture) dbefore dtheir dnumbers dare daffected dby dthe dantibiotic;
dthe dtest dwill dalso ddetermine dwhether dthe dproper dantibiotic dhas dbeen dordered d(sensitivity
dtesting). dAlthough dantibiotic dadministration dshould dnot dbe dunduly ddelayed dwhile dwaiting dfor
dthe dpatient dto dexpectorate dsputum, dall dof dthe dother doptions dwill dnot dbe daffected dby dthe
dadministration dof dantibiotics.
13. dWhich dof dthe dfollowing dnursing dinterventions dis dmost dappropriate dto denhance
doxygenation din da dpatient dwith dunilateral dmalignant dlung ddisease? d
A. dPositioning dpatient don dright dside. d
B. dMaintaining dadequate dfluid dintake d
C. dPerforming dpostural ddrainage devery d4 dhours d
D. dPositioning dpatient dwith d"good dlung ddown" d- d dCORRECT dANSWERS d dD. dPositioning dpatient
dwith d"good dlung ddown" dTherapeutic dpositioning didentifies dthe dbest dposition dfor dthe dpatient
dassuring dstable doxygenation dstatus. dResearch dindicates dthat dpositioning dthe dpatient dwith dthe
dunaffected dlung d(good dlung) ddependent dbest dpromotes doxygenation din dpatients dwith
dunilateral dlung ddisease. dFor dbilateral dlung ddisease, dthe dright dlung ddown dhas dbest dventilation
