HESI Med Surg 2022
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 - 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.
a2. 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.
a3. 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.
a4. 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.
a5. 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.
a6. 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.
a7. 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.
a8. 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.
a9. 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. - 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.
a10. 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) - 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.
a11. The nurse evaluates that discharge teaching for a patient
hospitalized with pneumonia has been most effective when the patient
states which of the following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my
immune system well."
B. "I must use home oxygen therapy for 3 months and then will have a
chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory
infections."
D. "I should continue to do deep-breathing and coughing exercises for
at least 6 weeks." - answer D. "I should continue to do deep-breathing
and coughing exercises for at least 6 weeks." It is important for the
patient to continue with coughing and deep breathing exercises for 6
to 8 weeks until all of the infection has cleared from the lungs. A
patient should seek medical treatment for upper respiratory infections
that persist for more than 7 days. Increased fluid intake, not caloric
intake, is required to liquefy secretions. Home O2 is not a requirement
unless the patient's oxygenation saturation is below normal.
a12. After admitting a patient to the medical unit with a diagnosis of
pneumonia, the nurse will verify that which of the following physician
orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient?
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 - 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.
a2. 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.
a3. 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.
a4. 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.
a5. 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.
a6. 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.
a7. 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.
a8. 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.
a9. 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. - 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.
a10. 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) - 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.
a11. The nurse evaluates that discharge teaching for a patient
hospitalized with pneumonia has been most effective when the patient
states which of the following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my
immune system well."
B. "I must use home oxygen therapy for 3 months and then will have a
chest x-ray to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory
infections."
D. "I should continue to do deep-breathing and coughing exercises for
at least 6 weeks." - answer D. "I should continue to do deep-breathing
and coughing exercises for at least 6 weeks." It is important for the
patient to continue with coughing and deep breathing exercises for 6
to 8 weeks until all of the infection has cleared from the lungs. A
patient should seek medical treatment for upper respiratory infections
that persist for more than 7 days. Increased fluid intake, not caloric
intake, is required to liquefy secretions. Home O2 is not a requirement
unless the patient's oxygenation saturation is below normal.
a12. After admitting a patient to the medical unit with a diagnosis of
pneumonia, the nurse will verify that which of the following physician
orders have been completed before administering a dose of cefotetan
(Cefotan) to the patient?
