HESI MED SURG v1 2025|Actual Exam Test(MULTIPLE
CHOICES) and (RATIONALES) questions and verified answers
|GET IT 100% ACCURATE!!
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 - VERIFIED 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.
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 - VERIFIED 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. - VERIFIED 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 - VERIFIED 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 - VERIFIED 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 - VERIFIED 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 - VERIFIED 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
- VERIFIED 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.
CHOICES) and (RATIONALES) questions and verified answers
|GET IT 100% ACCURATE!!
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 - VERIFIED 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.
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 - VERIFIED 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. - VERIFIED 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 - VERIFIED 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 - VERIFIED 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 - VERIFIED 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 - VERIFIED 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
- VERIFIED 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.
