(Complete 320 Q&A ) HESI Med Surg I Test Bank 2023 All
Answers Verified Correct. 150 QUESTIONS AND
ANSWERS
1. Which of the following nursing interventions is most appropriate to enhance
oxygenation in a patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down" ✔✔ D. Positioning patient with "good lung
down" Therapeutic positioning identifies the best position for the patient assuring stable
oxygenation status. Research indicates that positioning the patient with the unaffected
lung (good lung) dependent best promotes oxygenation in patients with unilateral lung
disease. For bilateral lung disease, the right lung down has best ventilation and
perfusion. Increasing fluid intake and performing postural drainage will facilitate airway
clearance, but positioning is most appropriate to enhance oxygenation.
2. A 71-year-old patient is admitted with acute respiratory distress related to cor
pulmonale. Which of the following nursing interventions is most appropriate during
admission of this patient?
A. Delay any physical assessment of the patient and review with the family the patient's
history of respiratory problems. B. Perform a comprehensive health history with the
patient to review prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific questions
related to this episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory
distress on other body functions. ✔✔ C. Perform a physical assessment of the
respiratory system and ask specific questions related to this episode of respiratory
distress.Because the patient is having respiratory difficulty, the nurse should ask
specific questions about this episode and perform a physical assessment of this system.
Further history taking and physical examination of other body systems can proceed
once the patient's acute respiratory distress is being managed.
3. When planning appropriate nursing interventions for a patient with metastatic lung
cancer and a 60-pack-year history of cigarette smoking, the nurse recognizes that the
smoking has most likely decreased the patient's underlying respiratory defenses
because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance ✔✔ D. Mucociliary clearance Smoking decreases the ciliary
action in the tracheobronchial tree, resulting in impaired clearance of respiratory
secretions, chronic cough, and frequent respiratory infections.
,4. While ambulating a patient with metastatic lung cancer, the nurse observes a drop
in oxygen saturation from 93% to 86%. Which of the following nursing interventions is
most appropriate based upon these findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate
monitoringduring activity.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation
and other activity.
D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen
saturation. ✔✔ C. Obtain a physician's order for supplemental oxygen to be used during
ambulation and other activity. An oxygen saturation level that drops below 90% with
activity indicates that the patient is not tolerating the exercise and needs to have
supplemental oxygen applied.
5. The nurse is caring for a 73-year-old patient who underwent a left total knee
arthroplasty. On the third postoperative day, the patient complains of shortness of
breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood
pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the
following should the nurse first suspect as the etiology of this episode?
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room ✔✔ B. Pulmonary
embolus from deep vein thrombosis The patient presents the classic symptoms of
pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and
chest pain.
6. In the case of pulmonary embolus from deep vein thrombosis, which of the following
actions should the nurse take first?
A. Notify the physician.
B. Administer a nitroglycerin tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen. ✔✔ D. Sit the patient up in
bed as tolerated and apply oxygen.The patient's clinical picture is consistent with
pulmonary embolus, and the first action the nurse takes should be to assist the patient.
For this reason, the nurse should sit the patient up as tolerated and apply oxygen before
notifying the physician.
7. The nurse is caring for a postoperative patient with sudden onset of respiratory
distress. The physician orders a STAT ventilation-perfusion scan. Which of the following
explanations should the nurse provide to the patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs,
followed by inhalation of a radioisotope gas.
B. This test will use special technology to examine cross sections of the chest with use
of a contrast dye.
,C. This test will use magnetic fields to produce images of the lungs and chest. D. This
test involves injecting contrast dye into a blood vessel to outline the blood vessels of the
lungs. ✔✔ A. This test involves injection of a radioisotope to outline the blood vessels in
the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has
two parts. In the perfusion portion, a radioisotope is injected into the blood and the
pulmonary vasculature is outlined. In the ventilation part, the patient inhales a
radioactive gas that outlines the alveoli.
8. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing
and dyspnea. The nurse interprets that these symptoms are related to which of the
following pathophysiologic changes? A. Laryngospasm B. Overdistention of the alveoli
C. Narrowing of the airway D. Pulmonary edema ✔✔ C. Narrowing of the
airwayNarrowing of the airway leads to reduced airflow, making it difficult for the patient
to breathe and producing the characteristic wheezing.
9. A 45-year-old man with asthma is brought to the emergency department by
automobile. He is short of breath and appears frightened. During the initial nursing
assessment, which of the following clinical manifestations might be present as an early
symptom during an exacerbation of asthma?
A. Anxiety
B. Cyanosis
C. Hypercapnia
D. Bradycardia ✔✔ A. Anxiety An early symptom during an asthma attack is anxiety
because he is acutely aware of the inability to get sufficient air to breathe. He will be
hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating.
10. The nurse is assigned to care for a patient who has anxiety and an exacerbation of
asthma. Which of the following is the primary reason for the nurse to carefully inspect
the chest wall of this patient?
A. Observe for signs of diaphoresis
B. Allow time to calm the patient
C. Monitor the patient for bilateral chest expansion
D. Evaluate the use of intercostal muscles ✔✔ D. Evaluate the use of intercostal
muscles The nurse physically inspects the chest wall to evaluate the use of intercostal
(accessory) muscles, which gives an indication of the degree of respiratory distress
experienced by the patient.
11. Which of the following positions is most appropriate for the nurse to place a patient
experiencing an asthma exacerbation?
A. Supine
B. Lithotomy
C. High-Fowler's
D. Reverse Trendelenburg ✔✔ C. High-Fowler'sThe patient experiencing an asthma
attack should be placed in high-Fowler's position to allow for optimal chest expansion
and enlist the aid of gravity during inspiration.
, 12. The nurse is caring for a patient with an acute exacerbation of asthma. Following
initial treatment, which of the following findings indicates to the nurse that the patient's
respiratory status is improving?
A. Wheezing becomes louder
B. Vesicular breath sounds decrease
C. Aerosol bronchodilators stimulate coughing
D. The cough remains nonproductive ✔✔ A. Wheezing becomes louder The primary
problem during an exacerbation of asthma is narrowing of the airway and subsequent
diminished air exchange. As the airways begin to dilate, wheezing gets louder because
of better air exchange.
13. The nurse identifies the nursing diagnosis of activity intolerance for a patient with
asthma. The nurse assesses for which of the following etiologic factor for this nursing
diagnosis in patients with asthma?
A. Anxiety and restlessness
B. Effects of medications
C. Fear of suffocation
D. Work of breathing ✔✔ D. Work of breathingWhen the patient does not have sufficient
gas exchange to engage in activity, the etiologic factor is often the work of breathing.
When patients with asthma do not have effective respirations, they use all available
energy to breathe and have little left over for purposeful activity.
14. The nurse is assigned to care for a patient in the emergency department admitted
with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator
and supplemental oxygen. If the patient's condition does not improve, the nurse should
anticipate which of the following is likely to be the next step in treatment?
A. Pulmonary function testing
B. Systemic corticosteroids
C. Biofeedback therapy
D. Intravenous fluids ✔✔ B. Systemic corticosteroids Systemic corticosteroids speed
the resolution of asthma exacerbations and are indicated if the initial response to the β-
adrenergic bronchodilator is insufficient.
15. A patient with acute exacerbation of COPD needs to receive precise amounts of
oxygen. Which of the following types of equipment should the nurse prepare to use?
A. Venturi mask
B. Partial non-rebreather mask
C. Oxygen tent
D. Nasal cannula ✔✔ A. Venturi mask The Venturi mask delivers precise concentrations
of oxygen and should be selected whenever this is a priority concern. The other
methods are less precise in terms of amount of oxygen delivered.
16. While teaching a patient with asthma about the appropriate use of a peak flow
meter, the nurse instructs the patient to do which of the following?
A. Use the flow meter each morning after taking medications to evaluate their
effectiveness.
Answers Verified Correct. 150 QUESTIONS AND
ANSWERS
1. Which of the following nursing interventions is most appropriate to enhance
oxygenation in a patient with unilateral malignant lung disease?
A. Positioning patient on right side.
B. Maintaining adequate fluid intake
C. Performing postural drainage every 4 hours
D. Positioning patient with "good lung down" ✔✔ D. Positioning patient with "good lung
down" Therapeutic positioning identifies the best position for the patient assuring stable
oxygenation status. Research indicates that positioning the patient with the unaffected
lung (good lung) dependent best promotes oxygenation in patients with unilateral lung
disease. For bilateral lung disease, the right lung down has best ventilation and
perfusion. Increasing fluid intake and performing postural drainage will facilitate airway
clearance, but positioning is most appropriate to enhance oxygenation.
2. A 71-year-old patient is admitted with acute respiratory distress related to cor
pulmonale. Which of the following nursing interventions is most appropriate during
admission of this patient?
A. Delay any physical assessment of the patient and review with the family the patient's
history of respiratory problems. B. Perform a comprehensive health history with the
patient to review prior respiratory problems.
C. Perform a physical assessment of the respiratory system and ask specific questions
related to this episode of respiratory distress.
D. Complete a full physical examination to determine the effect of the respiratory
distress on other body functions. ✔✔ C. Perform a physical assessment of the
respiratory system and ask specific questions related to this episode of respiratory
distress.Because the patient is having respiratory difficulty, the nurse should ask
specific questions about this episode and perform a physical assessment of this system.
Further history taking and physical examination of other body systems can proceed
once the patient's acute respiratory distress is being managed.
3. When planning appropriate nursing interventions for a patient with metastatic lung
cancer and a 60-pack-year history of cigarette smoking, the nurse recognizes that the
smoking has most likely decreased the patient's underlying respiratory defenses
because of impairment of which of the following?
A. Reflex bronchoconstriction
B. Ability to filter particles from the air
C. Cough reflex
D. Mucociliary clearance ✔✔ D. Mucociliary clearance Smoking decreases the ciliary
action in the tracheobronchial tree, resulting in impaired clearance of respiratory
secretions, chronic cough, and frequent respiratory infections.
,4. While ambulating a patient with metastatic lung cancer, the nurse observes a drop
in oxygen saturation from 93% to 86%. Which of the following nursing interventions is
most appropriate based upon these findings?
A. Continue with ambulation as this is a normal response to activity.
B. Move the oximetry probe from the finger to the earlobe for more accurate
monitoringduring activity.
C. Obtain a physician's order for supplemental oxygen to be used during ambulation
and other activity.
D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen
saturation. ✔✔ C. Obtain a physician's order for supplemental oxygen to be used during
ambulation and other activity. An oxygen saturation level that drops below 90% with
activity indicates that the patient is not tolerating the exercise and needs to have
supplemental oxygen applied.
5. The nurse is caring for a 73-year-old patient who underwent a left total knee
arthroplasty. On the third postoperative day, the patient complains of shortness of
breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood
pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the
following should the nurse first suspect as the etiology of this episode?
A. Septic embolus from the knee joint
B. Pulmonary embolus from deep vein thrombosis
C. New onset of angina pectoris
D. Pleural effusion related to positioning in the operating room ✔✔ B. Pulmonary
embolus from deep vein thrombosis The patient presents the classic symptoms of
pulmonary embolus: acute onset of symptoms, tachypnea, shortness of breath, and
chest pain.
6. In the case of pulmonary embolus from deep vein thrombosis, which of the following
actions should the nurse take first?
A. Notify the physician.
B. Administer a nitroglycerin tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen. ✔✔ D. Sit the patient up in
bed as tolerated and apply oxygen.The patient's clinical picture is consistent with
pulmonary embolus, and the first action the nurse takes should be to assist the patient.
For this reason, the nurse should sit the patient up as tolerated and apply oxygen before
notifying the physician.
7. The nurse is caring for a postoperative patient with sudden onset of respiratory
distress. The physician orders a STAT ventilation-perfusion scan. Which of the following
explanations should the nurse provide to the patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the lungs,
followed by inhalation of a radioisotope gas.
B. This test will use special technology to examine cross sections of the chest with use
of a contrast dye.
,C. This test will use magnetic fields to produce images of the lungs and chest. D. This
test involves injecting contrast dye into a blood vessel to outline the blood vessels of the
lungs. ✔✔ A. This test involves injection of a radioisotope to outline the blood vessels in
the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has
two parts. In the perfusion portion, a radioisotope is injected into the blood and the
pulmonary vasculature is outlined. In the ventilation part, the patient inhales a
radioactive gas that outlines the alveoli.
8. During assessment of a 45-year-old patient with asthma, the nurse notes wheezing
and dyspnea. The nurse interprets that these symptoms are related to which of the
following pathophysiologic changes? A. Laryngospasm B. Overdistention of the alveoli
C. Narrowing of the airway D. Pulmonary edema ✔✔ C. Narrowing of the
airwayNarrowing of the airway leads to reduced airflow, making it difficult for the patient
to breathe and producing the characteristic wheezing.
9. A 45-year-old man with asthma is brought to the emergency department by
automobile. He is short of breath and appears frightened. During the initial nursing
assessment, which of the following clinical manifestations might be present as an early
symptom during an exacerbation of asthma?
A. Anxiety
B. Cyanosis
C. Hypercapnia
D. Bradycardia ✔✔ A. Anxiety An early symptom during an asthma attack is anxiety
because he is acutely aware of the inability to get sufficient air to breathe. He will be
hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating.
10. The nurse is assigned to care for a patient who has anxiety and an exacerbation of
asthma. Which of the following is the primary reason for the nurse to carefully inspect
the chest wall of this patient?
A. Observe for signs of diaphoresis
B. Allow time to calm the patient
C. Monitor the patient for bilateral chest expansion
D. Evaluate the use of intercostal muscles ✔✔ D. Evaluate the use of intercostal
muscles The nurse physically inspects the chest wall to evaluate the use of intercostal
(accessory) muscles, which gives an indication of the degree of respiratory distress
experienced by the patient.
11. Which of the following positions is most appropriate for the nurse to place a patient
experiencing an asthma exacerbation?
A. Supine
B. Lithotomy
C. High-Fowler's
D. Reverse Trendelenburg ✔✔ C. High-Fowler'sThe patient experiencing an asthma
attack should be placed in high-Fowler's position to allow for optimal chest expansion
and enlist the aid of gravity during inspiration.
, 12. The nurse is caring for a patient with an acute exacerbation of asthma. Following
initial treatment, which of the following findings indicates to the nurse that the patient's
respiratory status is improving?
A. Wheezing becomes louder
B. Vesicular breath sounds decrease
C. Aerosol bronchodilators stimulate coughing
D. The cough remains nonproductive ✔✔ A. Wheezing becomes louder The primary
problem during an exacerbation of asthma is narrowing of the airway and subsequent
diminished air exchange. As the airways begin to dilate, wheezing gets louder because
of better air exchange.
13. The nurse identifies the nursing diagnosis of activity intolerance for a patient with
asthma. The nurse assesses for which of the following etiologic factor for this nursing
diagnosis in patients with asthma?
A. Anxiety and restlessness
B. Effects of medications
C. Fear of suffocation
D. Work of breathing ✔✔ D. Work of breathingWhen the patient does not have sufficient
gas exchange to engage in activity, the etiologic factor is often the work of breathing.
When patients with asthma do not have effective respirations, they use all available
energy to breathe and have little left over for purposeful activity.
14. The nurse is assigned to care for a patient in the emergency department admitted
with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator
and supplemental oxygen. If the patient's condition does not improve, the nurse should
anticipate which of the following is likely to be the next step in treatment?
A. Pulmonary function testing
B. Systemic corticosteroids
C. Biofeedback therapy
D. Intravenous fluids ✔✔ B. Systemic corticosteroids Systemic corticosteroids speed
the resolution of asthma exacerbations and are indicated if the initial response to the β-
adrenergic bronchodilator is insufficient.
15. A patient with acute exacerbation of COPD needs to receive precise amounts of
oxygen. Which of the following types of equipment should the nurse prepare to use?
A. Venturi mask
B. Partial non-rebreather mask
C. Oxygen tent
D. Nasal cannula ✔✔ A. Venturi mask The Venturi mask delivers precise concentrations
of oxygen and should be selected whenever this is a priority concern. The other
methods are less precise in terms of amount of oxygen delivered.
16. While teaching a patient with asthma about the appropriate use of a peak flow
meter, the nurse instructs the patient to do which of the following?
A. Use the flow meter each morning after taking medications to evaluate their
effectiveness.
