HESI MED-SURG EXAM. QUESTIONS AND ANSWERS. LATEST 2022. A+ RATED

HESI Med Surg Exam Questions and Answers with

Explanations

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

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

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.

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

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

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

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

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

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.

D. 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?

A. S. aureus

B. H. influenzae

C. Pneumococcal

D. 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?

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."

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.