ESTUDYR
MED SURG TEST BANK ( RED HESI TEST BANK
MED-SURG AND OTHER RESOURCES)
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 ✅
Rationale: Clubbing (an increased angle at the nail base and spongy fingertip) is a classic
sign of chronic hypoxemia.
2. For an arterial blood gas (ABG) puncture in a patient with COPD and pneumonia, the
nurse should plan to hold pressure on the puncture site for at least:
A. 2 minutes
B. 5 minutes ✅
C. 10 minutes
D. 15 minutes
Rationale: Because arteries are high-pressure vessels, 5 minutes of direct pressure is the
minimum commonly recommended to prevent hematoma/bleeding.
3. A patient with facial trauma has clear nasal drainage. The nurse should:
A. Test the drainage for the presence of glucose ✅
B. Suction the nose to maintain airway clearance
C. Document and continue monitoring
D. Apply a drip pad and reassure the patient
Rationale: Clear drainage after facial trauma may be CSF; testing for glucose helps
identify CSF leak and prompts neurosurgical evaluation.
4. Three hours after a laryngectomy, the nurse's highest priority assessment is:
A. Airway patency ✅
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
Rationale: Airway safety (ABCs) is paramount after upper airway surgery.
5. When initially teaching the supraglottic swallow after radical neck dissection, begin with
which food/liquid?
,ESTUDYR
A. Cola (carbonated beverage) ✅
B. Applesauce
C. French fries
D. White grape juice
Rationale: Carbonation gives sensory cues that help patients detect bolus position and
initiate safer swallow techniques; thin, non-carbonated liquids are riskier.
6. A patient with pneumonia: temperature 101.4°F, productive yellow cough, RR 20. The
most appropriate nursing diagnosis is:
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
Rationale: Fever indicates hyperthermia due to infection; other options are less directly
supported by the given data.
7. Which physical assessment finding best supports a nursing diagnosis of ineffective
airway clearance in pneumonia?
A. Oxygen saturation 85%
B. Respiratory rate 28
C. Presence of greenish sputum
D. Basilar crackles ✅
Rationale: Adventitious breath sounds (crackles) indicate secretions/consolidation in
the lower airways consistent with retained secretions.
8. In pneumococcal pneumonia, which finding is expected on exam?
A. Hyperresonance on percussion
B. Fine crackles in all lobes
C. Increased vocal fremitus on palpation ✅
D. Vesicular breath sounds in all lobes
Rationale: Consolidation increases transmission of voice vibrations (fremitus);
percussion is typically dull over consolidation.
9. The highest-priority nursing intervention to help a patient expectorate thick secretions
is:
A. Humidify the oxygen as able
B. Increase fluid intake to 3 L/day if tolerated ✅
C. Administer cough suppressant q4hr
D. Teach patient to splint the affected area
,ESTUDYR
Rationale: Adequate hydration thins secretions making expectoration easier; cough
suppressants would hinder clearance.
10. On discharge teaching for a 65-year-old with emphysema and pneumonia, which
vaccine should be recommended?
A. S. aureus
B. H. influenzae
C. Pneumococcal ✅
D. Bacille Calmette-Guérin (BCG)
Rationale: Pneumococcal vaccination is recommended for those ≥65 and with chronic
lung disease to reduce invasive pneumococcal disease.
11. Discharge teaching was most effective when the patient states which measure to
prevent relapse?
A. Increase food intake to 2400 kcal/day
B. Use home O₂ for 3 months then get CXR
C. Seek immediate treatment for any URI
D. Continue deep-breathing and coughing exercises for at least 6 weeks ✅
Rationale: Continued pulmonary hygiene (deep breathing, coughing) supports clearance
and recovery; it’s standard post-pneumonia teaching.
12. Before administering cefotetan to a patient admitted with pneumonia, the nurse should
verify completion of:
A. Serum lab studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity ✅
Rationale: Obtain sputum for culture before first dose of antibiotics to identify causative
organism and guide therapy.
13. To enhance oxygenation in unilateral malignant lung disease, the best positioning is:
A. Position on right side
B. Maintain adequate fluid intake
C. Perform postural drainage q4h
D. Position with “good lung down” (affected lung up) ✅
Rationale: Placing the healthy lung dependent (down) optimizes V/Q matching and
oxygenation in unilateral disease.
14. A 71-year-old with acute respiratory distress related to cor pulmonale — the most
appropriate immediate nursing action on admission is:
, ESTUDYR
A. Delay assessment and review history with family
B. Perform comprehensive health history with patient
C. Perform focused respiratory assessment and ask about this episode ✅
D. Complete full physical exam of all systems
Rationale: Acute respiratory distress requires focused respiratory assessment and
targeted questions to stabilize the patient first.
15. Chronic smoking most impairs which respiratory defense mechanism?
A. Reflex bronchoconstriction
B. Ability to filter particles from air
C. Cough reflex
D. Mucociliary clearance ✅
Rationale: Smoking damages cilia and mucociliary escalator, impairing clearance of
secretions and pathogens.
16. Ambulating a patient with metastatic lung cancer results in SpO₂ drop from 93% to 86%.
The most appropriate action is:
A. Continue ambulation (normal response)
B. Move probe to earlobe for accuracy
C. Obtain physician order for supplemental oxygen during activity ✅
D. Order ABGs to verify saturation
Rationale: Saturation <90% with activity indicates need for supplemental O₂ during
exertion to maintain adequate oxygenation.
17. A 73-year-old on post-op day 3 with sudden dyspnea, RR 36, SpO₂ 91%, slight chest pain
— most likely cause:
A. Septic embolus from knee joint
B. Pulmonary embolus from DVT ✅
C. New onset angina
D. Pleural effusion from OR positioning
Rationale: Sudden dyspnea/tachypnea post-op suggests pulmonary embolism as the
prime suspect.
18. For a suspected pulmonary embolus, the nurse’s first action should be:
A. Notify the physician
B. Give sublingual nitroglycerin
C. Conduct thorough chest pain assessment
D. Sit patient up as tolerated and apply oxygen ✅
Rationale: Immediate supportive care (upright position, O₂) to improve
ventilation/perfusion precedes notification and diagnostic steps.
MED SURG TEST BANK ( RED HESI TEST BANK
MED-SURG AND OTHER RESOURCES)
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 ✅
Rationale: Clubbing (an increased angle at the nail base and spongy fingertip) is a classic
sign of chronic hypoxemia.
2. For an arterial blood gas (ABG) puncture in a patient with COPD and pneumonia, the
nurse should plan to hold pressure on the puncture site for at least:
A. 2 minutes
B. 5 minutes ✅
C. 10 minutes
D. 15 minutes
Rationale: Because arteries are high-pressure vessels, 5 minutes of direct pressure is the
minimum commonly recommended to prevent hematoma/bleeding.
3. A patient with facial trauma has clear nasal drainage. The nurse should:
A. Test the drainage for the presence of glucose ✅
B. Suction the nose to maintain airway clearance
C. Document and continue monitoring
D. Apply a drip pad and reassure the patient
Rationale: Clear drainage after facial trauma may be CSF; testing for glucose helps
identify CSF leak and prompts neurosurgical evaluation.
4. Three hours after a laryngectomy, the nurse's highest priority assessment is:
A. Airway patency ✅
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate
Rationale: Airway safety (ABCs) is paramount after upper airway surgery.
5. When initially teaching the supraglottic swallow after radical neck dissection, begin with
which food/liquid?
,ESTUDYR
A. Cola (carbonated beverage) ✅
B. Applesauce
C. French fries
D. White grape juice
Rationale: Carbonation gives sensory cues that help patients detect bolus position and
initiate safer swallow techniques; thin, non-carbonated liquids are riskier.
6. A patient with pneumonia: temperature 101.4°F, productive yellow cough, RR 20. The
most appropriate nursing diagnosis is:
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
Rationale: Fever indicates hyperthermia due to infection; other options are less directly
supported by the given data.
7. Which physical assessment finding best supports a nursing diagnosis of ineffective
airway clearance in pneumonia?
A. Oxygen saturation 85%
B. Respiratory rate 28
C. Presence of greenish sputum
D. Basilar crackles ✅
Rationale: Adventitious breath sounds (crackles) indicate secretions/consolidation in
the lower airways consistent with retained secretions.
8. In pneumococcal pneumonia, which finding is expected on exam?
A. Hyperresonance on percussion
B. Fine crackles in all lobes
C. Increased vocal fremitus on palpation ✅
D. Vesicular breath sounds in all lobes
Rationale: Consolidation increases transmission of voice vibrations (fremitus);
percussion is typically dull over consolidation.
9. The highest-priority nursing intervention to help a patient expectorate thick secretions
is:
A. Humidify the oxygen as able
B. Increase fluid intake to 3 L/day if tolerated ✅
C. Administer cough suppressant q4hr
D. Teach patient to splint the affected area
,ESTUDYR
Rationale: Adequate hydration thins secretions making expectoration easier; cough
suppressants would hinder clearance.
10. On discharge teaching for a 65-year-old with emphysema and pneumonia, which
vaccine should be recommended?
A. S. aureus
B. H. influenzae
C. Pneumococcal ✅
D. Bacille Calmette-Guérin (BCG)
Rationale: Pneumococcal vaccination is recommended for those ≥65 and with chronic
lung disease to reduce invasive pneumococcal disease.
11. Discharge teaching was most effective when the patient states which measure to
prevent relapse?
A. Increase food intake to 2400 kcal/day
B. Use home O₂ for 3 months then get CXR
C. Seek immediate treatment for any URI
D. Continue deep-breathing and coughing exercises for at least 6 weeks ✅
Rationale: Continued pulmonary hygiene (deep breathing, coughing) supports clearance
and recovery; it’s standard post-pneumonia teaching.
12. Before administering cefotetan to a patient admitted with pneumonia, the nurse should
verify completion of:
A. Serum lab studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity ✅
Rationale: Obtain sputum for culture before first dose of antibiotics to identify causative
organism and guide therapy.
13. To enhance oxygenation in unilateral malignant lung disease, the best positioning is:
A. Position on right side
B. Maintain adequate fluid intake
C. Perform postural drainage q4h
D. Position with “good lung down” (affected lung up) ✅
Rationale: Placing the healthy lung dependent (down) optimizes V/Q matching and
oxygenation in unilateral disease.
14. A 71-year-old with acute respiratory distress related to cor pulmonale — the most
appropriate immediate nursing action on admission is:
, ESTUDYR
A. Delay assessment and review history with family
B. Perform comprehensive health history with patient
C. Perform focused respiratory assessment and ask about this episode ✅
D. Complete full physical exam of all systems
Rationale: Acute respiratory distress requires focused respiratory assessment and
targeted questions to stabilize the patient first.
15. Chronic smoking most impairs which respiratory defense mechanism?
A. Reflex bronchoconstriction
B. Ability to filter particles from air
C. Cough reflex
D. Mucociliary clearance ✅
Rationale: Smoking damages cilia and mucociliary escalator, impairing clearance of
secretions and pathogens.
16. Ambulating a patient with metastatic lung cancer results in SpO₂ drop from 93% to 86%.
The most appropriate action is:
A. Continue ambulation (normal response)
B. Move probe to earlobe for accuracy
C. Obtain physician order for supplemental oxygen during activity ✅
D. Order ABGs to verify saturation
Rationale: Saturation <90% with activity indicates need for supplemental O₂ during
exertion to maintain adequate oxygenation.
17. A 73-year-old on post-op day 3 with sudden dyspnea, RR 36, SpO₂ 91%, slight chest pain
— most likely cause:
A. Septic embolus from knee joint
B. Pulmonary embolus from DVT ✅
C. New onset angina
D. Pleural effusion from OR positioning
Rationale: Sudden dyspnea/tachypnea post-op suggests pulmonary embolism as the
prime suspect.
18. For a suspected pulmonary embolus, the nurse’s first action should be:
A. Notify the physician
B. Give sublingual nitroglycerin
C. Conduct thorough chest pain assessment
D. Sit patient up as tolerated and apply oxygen ✅
Rationale: Immediate supportive care (upright position, O₂) to improve
ventilation/perfusion precedes notification and diagnostic steps.
