NGN HESI MED SURG Exam
Questions and Correct Verified
Answers (with Rationales) Latest
update 2024/2025 GRADED A+
Guaranteed pass
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. - 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.
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 - 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.
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 - 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.
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 - 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.
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 - 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.
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 - 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.
A patient with COPD is receiving oxygen at 2 L/min.
While in the supine position for a bath, the patient
complains of shortness of breath. What is the most
appropriate first nursing action?
A. Increase the flow of oxygen.
Questions and Correct Verified
Answers (with Rationales) Latest
update 2024/2025 GRADED A+
Guaranteed pass
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. - 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.
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 - 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.
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 - 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.
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 - 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.
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 - 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.
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 - 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.
A patient with COPD is receiving oxygen at 2 L/min.
While in the supine position for a bath, the patient
complains of shortness of breath. What is the most
appropriate first nursing action?
A. Increase the flow of oxygen.
