MED SURG TEST BANK ( RED HESI TEST BANK MED-SURG AND OTHER
RESOURCES) EXAM QUESTIONS AND ANSWERS LATEST UPDATE 2025/2026
ALL ANSWERS CORRECT VERIFIED TO SCORE A+ FOR SUCCESS
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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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. - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS
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 fof fthe ffollowing fnursing finterventions fis fof fthe fhighest fpriority fin fhelping fa fpatient
fexpectorate fthick fsecretions frelated fto fpneumonia? f
A. fHumidify fthe foxygen fas fable f
B. fIncrease ffluid fintake fto f3L/day fif ftolerated. f
C. fAdminister fcough fsuppressant fq4hr. f
D. fTeach fpatient fto fsplint fthe faffected farea. f- f fCORRECT fANSWERS f fB. fIncrease ffluid fintake fto
f3L/day fif ftolerated. fAlthough fseveral finterventions fmay fhelp fthe fpatient fexpectorate fmucus, fthe
fhighest fpriority fshould fbe fon fincreasing ffluid fintake, fwhich fwill fliquefy fthe fsecretions fso fthat
fthe fpatient fcan fexpectorate fthem fmore feasily. fHumidifying fthe foxygen fis falso fhelpful, fbut fis
fnot fthe fprimary fintervention. fTeaching fthe fpatient fto fsplint fthe faffected farea fmay falso fbe
fhelpful, fbut fdoes fnot fliquefy fthe fsecretions fso fthat fthey fcan fbe fremoved.
10. fDuring fdischarge fteaching ffor fa f65-year-old fpatient fwith femphysema fand fpneumonia, fwhich
fof fthe ffollowing fvaccines fshould fthe fnurse frecommend fthe fpatient freceive? f
A. fS. faureus f
B. fH. finfluenzae f
C. fPneumococcal f
D. fBacille fCalmette-Guérin f(BCG) f- f fCORRECT fANSWERS f fC. fPneumococcal fThe fpneumococcal
fvaccine fis fimportant ffor fpatients fwith fa fhistory fof fheart for flung fdisease, frecovering ffrom fa
fsevere fillness, fage f65 for fover, for fliving fin fa flong-term fcare ffacility.
11. fThe fnurse fevaluates fthat fdischarge fteaching ffor fa fpatient fhospitalized fwith fpneumonia fhas
fbeen fmost feffective fwhen fthe fpatient fstates fwhich fof fthe ffollowing fmeasures fto fprevent fa
frelapse? f
A. f"I fwill fincrease fmy ffood fintake fto f2400 fcalories fa fday fto fkeep fmy fimmune fsystem fwell." f
, B. f"I fmust fuse fhome foxygen ftherapy ffor f3 fmonths fand fthen fwill fhave fa fchest fx-ray fto
freevaluate." f
C. f"I fwill fseek fimmediate fmedical ftreatment ffor fany fupper frespiratory finfections." f
D. f"I fshould fcontinue fto fdo fdeep-breathing fand fcoughing fexercises ffor fat fleast f6 fweeks." f- f
fCORRECT fANSWERS f fD. f"I fshould fcontinue fto fdo fdeep-breathing fand fcoughing fexercises ffor fat
fleast f6 fweeks." fIt fis fimportant ffor fthe fpatient fto fcontinue fwith fcoughing fand fdeep fbreathing
fexercises ffor f6 fto f8 fweeks funtil fall fof fthe finfection fhas fcleared ffrom fthe flungs. fA fpatient
fshould fseek fmedical ftreatment ffor fupper frespiratory finfections fthat fpersist ffor fmore fthan f7
fdays. fIncreased ffluid fintake, fnot fcaloric fintake, fis frequired fto fliquefy fsecretions. fHome fO2 fis fnot
fa frequirement funless fthe fpatient's foxygenation fsaturation fis fbelow fnormal.
12. fAfter fadmitting fa fpatient fto fthe fmedical funit fwith fa fdiagnosis fof fpneumonia, fthe fnurse fwill
fverify fthat fwhich fof fthe ffollowing fphysician forders fhave fbeen fcompleted fbefore fadministering fa
fdose fof fcefotetan f(Cefotan) fto fthe fpatient? f
A. fSerum flaboratory fstudies fordered ffor fAM f
B. fPulmonary ffunction fevaluation f
C. fOrthostatic fblood fpressures f
D. fSputum fculture fand fsensitivity f- f fCORRECT fANSWERS f fD. fSputum fculture fand fsensitivityThe
fnurse fshould fensure fthat fthe fsputum ffor fculture fand fsensitivity fwas fsent fto fthe flaboratory
fbefore fadministering fthe fcefotetan. fIt fis fimportant fthat fthe forganisms fare fcorrectly fidentified
f(by fthe fculture) fbefore ftheir fnumbers fare faffected fby fthe fantibiotic; fthe ftest fwill falso
fdetermine fwhether fthe fproper fantibiotic fhas fbeen fordered f(sensitivity ftesting). fAlthough
fantibiotic fadministration fshould fnot fbe funduly fdelayed fwhile fwaiting ffor fthe fpatient fto
fexpectorate fsputum, fall fof fthe fother foptions fwill fnot fbe faffected fby fthe fadministration fof
fantibiotics.
13. fWhich fof fthe ffollowing fnursing finterventions fis fmost fappropriate fto fenhance foxygenation fin
fa fpatient fwith funilateral fmalignant flung fdisease? f
A. fPositioning fpatient fon fright fside. f
B. fMaintaining fadequate ffluid fintake f
C. fPerforming fpostural fdrainage fevery f4 fhours f
D. fPositioning fpatient fwith f"good flung fdown" f- f fCORRECT fANSWERS f fD. fPositioning fpatient fwith
f"good flung fdown" fTherapeutic fpositioning fidentifies fthe fbest fposition ffor fthe fpatient fassuring
fstable foxygenation fstatus. fResearch findicates fthat fpositioning fthe fpatient fwith fthe funaffected
flung f(good flung) fdependent fbest fpromotes foxygenation fin fpatients fwith funilateral flung fdisease.
fFor fbilateral flung fdisease, fthe fright flung fdown fhas fbest fventilation fand fperfusion. fIncreasing
ffluid fintake fand fperforming fpostural fdrainage fwill ffacilitate fairway fclearance, fbut fpositioning fis
fmost fappropriate fto fenhance foxygenation.
RESOURCES) EXAM QUESTIONS AND ANSWERS LATEST UPDATE 2025/2026
ALL ANSWERS CORRECT VERIFIED TO SCORE A+ FOR SUCCESS
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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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. - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS 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 - CORRECT ANSWERS
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 fof fthe ffollowing fnursing finterventions fis fof fthe fhighest fpriority fin fhelping fa fpatient
fexpectorate fthick fsecretions frelated fto fpneumonia? f
A. fHumidify fthe foxygen fas fable f
B. fIncrease ffluid fintake fto f3L/day fif ftolerated. f
C. fAdminister fcough fsuppressant fq4hr. f
D. fTeach fpatient fto fsplint fthe faffected farea. f- f fCORRECT fANSWERS f fB. fIncrease ffluid fintake fto
f3L/day fif ftolerated. fAlthough fseveral finterventions fmay fhelp fthe fpatient fexpectorate fmucus, fthe
fhighest fpriority fshould fbe fon fincreasing ffluid fintake, fwhich fwill fliquefy fthe fsecretions fso fthat
fthe fpatient fcan fexpectorate fthem fmore feasily. fHumidifying fthe foxygen fis falso fhelpful, fbut fis
fnot fthe fprimary fintervention. fTeaching fthe fpatient fto fsplint fthe faffected farea fmay falso fbe
fhelpful, fbut fdoes fnot fliquefy fthe fsecretions fso fthat fthey fcan fbe fremoved.
10. fDuring fdischarge fteaching ffor fa f65-year-old fpatient fwith femphysema fand fpneumonia, fwhich
fof fthe ffollowing fvaccines fshould fthe fnurse frecommend fthe fpatient freceive? f
A. fS. faureus f
B. fH. finfluenzae f
C. fPneumococcal f
D. fBacille fCalmette-Guérin f(BCG) f- f fCORRECT fANSWERS f fC. fPneumococcal fThe fpneumococcal
fvaccine fis fimportant ffor fpatients fwith fa fhistory fof fheart for flung fdisease, frecovering ffrom fa
fsevere fillness, fage f65 for fover, for fliving fin fa flong-term fcare ffacility.
11. fThe fnurse fevaluates fthat fdischarge fteaching ffor fa fpatient fhospitalized fwith fpneumonia fhas
fbeen fmost feffective fwhen fthe fpatient fstates fwhich fof fthe ffollowing fmeasures fto fprevent fa
frelapse? f
A. f"I fwill fincrease fmy ffood fintake fto f2400 fcalories fa fday fto fkeep fmy fimmune fsystem fwell." f
, B. f"I fmust fuse fhome foxygen ftherapy ffor f3 fmonths fand fthen fwill fhave fa fchest fx-ray fto
freevaluate." f
C. f"I fwill fseek fimmediate fmedical ftreatment ffor fany fupper frespiratory finfections." f
D. f"I fshould fcontinue fto fdo fdeep-breathing fand fcoughing fexercises ffor fat fleast f6 fweeks." f- f
fCORRECT fANSWERS f fD. f"I fshould fcontinue fto fdo fdeep-breathing fand fcoughing fexercises ffor fat
fleast f6 fweeks." fIt fis fimportant ffor fthe fpatient fto fcontinue fwith fcoughing fand fdeep fbreathing
fexercises ffor f6 fto f8 fweeks funtil fall fof fthe finfection fhas fcleared ffrom fthe flungs. fA fpatient
fshould fseek fmedical ftreatment ffor fupper frespiratory finfections fthat fpersist ffor fmore fthan f7
fdays. fIncreased ffluid fintake, fnot fcaloric fintake, fis frequired fto fliquefy fsecretions. fHome fO2 fis fnot
fa frequirement funless fthe fpatient's foxygenation fsaturation fis fbelow fnormal.
12. fAfter fadmitting fa fpatient fto fthe fmedical funit fwith fa fdiagnosis fof fpneumonia, fthe fnurse fwill
fverify fthat fwhich fof fthe ffollowing fphysician forders fhave fbeen fcompleted fbefore fadministering fa
fdose fof fcefotetan f(Cefotan) fto fthe fpatient? f
A. fSerum flaboratory fstudies fordered ffor fAM f
B. fPulmonary ffunction fevaluation f
C. fOrthostatic fblood fpressures f
D. fSputum fculture fand fsensitivity f- f fCORRECT fANSWERS f fD. fSputum fculture fand fsensitivityThe
fnurse fshould fensure fthat fthe fsputum ffor fculture fand fsensitivity fwas fsent fto fthe flaboratory
fbefore fadministering fthe fcefotetan. fIt fis fimportant fthat fthe forganisms fare fcorrectly fidentified
f(by fthe fculture) fbefore ftheir fnumbers fare faffected fby fthe fantibiotic; fthe ftest fwill falso
fdetermine fwhether fthe fproper fantibiotic fhas fbeen fordered f(sensitivity ftesting). fAlthough
fantibiotic fadministration fshould fnot fbe funduly fdelayed fwhile fwaiting ffor fthe fpatient fto
fexpectorate fsputum, fall fof fthe fother foptions fwill fnot fbe faffected fby fthe fadministration fof
fantibiotics.
13. fWhich fof fthe ffollowing fnursing finterventions fis fmost fappropriate fto fenhance foxygenation fin
fa fpatient fwith funilateral fmalignant flung fdisease? f
A. fPositioning fpatient fon fright fside. f
B. fMaintaining fadequate ffluid fintake f
C. fPerforming fpostural fdrainage fevery f4 fhours f
D. fPositioning fpatient fwith f"good flung fdown" f- f fCORRECT fANSWERS f fD. fPositioning fpatient fwith
f"good flung fdown" fTherapeutic fpositioning fidentifies fthe fbest fposition ffor fthe fpatient fassuring
fstable foxygenation fstatus. fResearch findicates fthat fpositioning fthe fpatient fwith fthe funaffected
flung f(good flung) fdependent fbest fpromotes foxygenation fin fpatients fwith funilateral flung fdisease.
fFor fbilateral flung fdisease, fthe fright flung fdown fhas fbest fventilation fand fperfusion. fIncreasing
ffluid fintake fand fperforming fpostural fdrainage fwill ffacilitate fairway fclearance, fbut fpositioning fis
fmost fappropriate fto fenhance foxygenation.
