MED SURG HESI V1 EXAM SCRIPT 2026
COMPLETE QUESTIONS AND ANSWERS
◉ 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. 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.. 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. 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. 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. 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. 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. 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.
COMPLETE QUESTIONS AND ANSWERS
◉ 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. 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.. 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. 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. 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. 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. 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. 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.
