HESI MED SURG- EXAM TEST BANK 20 + QUESTIONS AND RATIONALE
ANSWERS 2025-2026
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
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
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.
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
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
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
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
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
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.
ANSWERS 2025-2026
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
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
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.
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
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
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
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
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
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.
