HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
The nurse assesses a patient with shortness of breath for evidence
of long-standing hypoxemia by inspecting:
o Chest excursion
o Spinal curvatures
o The respiratory pattern
o 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?
o 2 minutes
o 5 minutes
o 10 minutes
o 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:
o test the drainage for the presence of glucose.
o suction the nose to maintain airway clearance.
o document the findings and continue monitoring.
o 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:
o Airway patency
o Patient comfort
o Incisional drainage
o 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.
, HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
5. When initially teaching a patient the supraglottic swallow following
a radical neck dissection, with which of the following foods should the
nurse begin?
o Cola
o Applesauce
o French fries
o 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. Hy- perthermia 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 clear- ance? 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?
o Hyperresonance on percussion
,HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
o Fine crackles in all lobes on auscultation
o Increased vocal fremitus on palpation D. Vesicular breath sounds in
all
, HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
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.
9. Which of the following nursing interventions is of the highest priority
in helping a patient expectorate thick secretions related to pneumonia?
o Humidify the oxygen as able
o Increase fluid intake to 3L/day if tolerated.
o Administer cough suppressant q4hr.
o Teach patient to splint the affected area.: 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?
o S. aureus
o H. influenzae
o Pneumococcal
o Bacille Calmette-Guérin (BCG): 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.
11. 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?
o "I will increase my food intake to 2400 calories a day to keep my
immune system well."
o "I must use home oxygen therapy for 3 months and then will have a
chest x-ray to reevaluate."
o "I will seek immediate medical treatment for any upper respiratory
infec- tions."
o "I should continue to do deep-breathing and coughing exercises for
at least 6 weeks.": 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
ANSWERS, GRADED AND APPROVED A+
The nurse assesses a patient with shortness of breath for evidence
of long-standing hypoxemia by inspecting:
o Chest excursion
o Spinal curvatures
o The respiratory pattern
o 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?
o 2 minutes
o 5 minutes
o 10 minutes
o 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:
o test the drainage for the presence of glucose.
o suction the nose to maintain airway clearance.
o document the findings and continue monitoring.
o 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:
o Airway patency
o Patient comfort
o Incisional drainage
o 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.
, HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
5. When initially teaching a patient the supraglottic swallow following
a radical neck dissection, with which of the following foods should the
nurse begin?
o Cola
o Applesauce
o French fries
o 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. Hy- perthermia 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 clear- ance? 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?
o Hyperresonance on percussion
,HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
o Fine crackles in all lobes on auscultation
o Increased vocal fremitus on palpation D. Vesicular breath sounds in
all
, HESI MED SURG UPDATED EXAM WITH COMPLETE QUESTIONS AND
ANSWERS, GRADED AND APPROVED A+
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.
9. Which of the following nursing interventions is of the highest priority
in helping a patient expectorate thick secretions related to pneumonia?
o Humidify the oxygen as able
o Increase fluid intake to 3L/day if tolerated.
o Administer cough suppressant q4hr.
o Teach patient to splint the affected area.: 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?
o S. aureus
o H. influenzae
o Pneumococcal
o Bacille Calmette-Guérin (BCG): 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.
11. 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?
o "I will increase my food intake to 2400 calories a day to keep my
immune system well."
o "I must use home oxygen therapy for 3 months and then will have a
chest x-ray to reevaluate."
o "I will seek immediate medical treatment for any upper respiratory
infec- tions."
o "I should continue to do deep-breathing and coughing exercises for
at least 6 weeks.": 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
