HESI Med Surg Exam NEWEST 2025 COMPLETE
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW VERSION!!
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.
QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY
GRADED A+||BRAND NEW VERSION!!
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.
