4/23/25, 3:13 PM HESI MED SURG v1 2025|Actual Exam Test(MULTIPLE CHOICES) and (RATIONALES) questions and verified answers |GET…
HESI MED SURG v1 2025|Actual Exam
Test(MULTIPLE CHOICES) and (RATIONALES)
questions and verified answers |GET IT 100%
ACCURATE!!
Save
Terms in this set (302)
The nurse assesses a D. The fingernail and its base Clubbing, a sign of
patient with shortness of long-standing hypoxemia, is evidenced by an
breath for evidence of increase in the angle between the base of the nail
long-standing hypoxemia and the fingernail to 180 degrees or more, usually
by inspecting: accompanied by an increase in the depth, bulk, and
A. Chest excursion sponginess of the end of the finger.
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its
base
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2. The nurse is caring for B. 5 minutes Following obtaining an arterial blood
a patient with COPD and gas, the nurse should hold pressure on the puncture
pneumonia who has an site for 5 minutes by the clock to be sure that
order for arterial blood bleeding has stopped. An artery is an elastic vessel
gases to be drawn. Which under higher pressure than veins, and significant
of the following is the blood loss or hematoma formation could occur if
minimum length of time the time is insufficient.
the nurse should plan to
hold pressure on the
puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
3. The nurse notices clear A. test the drainage for the presence of glucose.
nasal drainage in a Clear nasal drainage suggests leakage of
patient newly admitted cerebrospinal fluid (CSF). The drainage should be
with facial trauma, tested for the presence of glucose, which would
including a nasal fracture. indicate the presence of CSF.
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.
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4. When caring for a A. Airway patency Remember ABCs with
patient who is 3 hours prioritization. Airway patency is always the highest
postoperative priority and is essential for a patient undergoing
laryngectomy, the nurse's surgery surrounding the upper respiratory system.
highest priority
assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and
heart rate
5. When initially teaching A. ColaWhen learning the supraglottic swallow, it
a patient the supraglottic may be helpful to start with carbonated beverages
swallow following a because the effervescence provides clues about
radical neck dissection, the liquid's position. Thin, watery fluids should be
with which of the avoided because they are difficult to swallow and
following foods should increase the risk of aspiration. Nonpourable pureed
the nurse begin? foods, such as applesauce, would decrease the risk
A. Cola of aspiration, but carbonated beverages are the
B. Applesauce better choice to start with.
C. French fries
D. White grape juice
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6. The nurse is caring for A. Hyperthermia related to infectious illness
a patient admitted to the Because the patient has spiked a temperature and
hospital with pneumonia. has a diagnosis of pneumonia, the logical nursing
Upon assessment, the diagnosis is hyperthermia related to infectious
nurse notes a illness. There is no evidence of a chill, and her
temperature of 101.4° F, a breathing pattern is within normal limits at 20
productive cough with breaths per minute. There is no evidence of
yellow sputum and a ineffective airway clearance from the information
respiratory rate of 20. given because the patient is expectorating sputum.
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
7. Which of the following D. Basilar crackles The presence of adventitious
physical assessment breath sounds indicates that there is accumulation of
findings in a patient with secretions in the lower airways. This would be
pneumonia best supports consistent with a nursing diagnosis of ineffective
the nursing diagnosis of airway clearance because the patient is retaining
ineffective airway secretions.
clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish
sputum
D. Basilar crackles
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HESI MED SURG v1 2025|Actual Exam
Test(MULTIPLE CHOICES) and (RATIONALES)
questions and verified answers |GET IT 100%
ACCURATE!!
Save
Terms in this set (302)
The nurse assesses a D. The fingernail and its base Clubbing, a sign of
patient with shortness of long-standing hypoxemia, is evidenced by an
breath for evidence of increase in the angle between the base of the nail
long-standing hypoxemia and the fingernail to 180 degrees or more, usually
by inspecting: accompanied by an increase in the depth, bulk, and
A. Chest excursion sponginess of the end of the finger.
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its
base
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,4/23/25, 3:13 PM HESI MED SURG v1 2025|Actual Exam Test(MULTIPLE CHOICES) and (RATIONALES) questions and verified answers |GET…
2. The nurse is caring for B. 5 minutes Following obtaining an arterial blood
a patient with COPD and gas, the nurse should hold pressure on the puncture
pneumonia who has an site for 5 minutes by the clock to be sure that
order for arterial blood bleeding has stopped. An artery is an elastic vessel
gases to be drawn. Which under higher pressure than veins, and significant
of the following is the blood loss or hematoma formation could occur if
minimum length of time the time is insufficient.
the nurse should plan to
hold pressure on the
puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
3. The nurse notices clear A. test the drainage for the presence of glucose.
nasal drainage in a Clear nasal drainage suggests leakage of
patient newly admitted cerebrospinal fluid (CSF). The drainage should be
with facial trauma, tested for the presence of glucose, which would
including a nasal fracture. indicate the presence of CSF.
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.
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,4/23/25, 3:13 PM HESI MED SURG v1 2025|Actual Exam Test(MULTIPLE CHOICES) and (RATIONALES) questions and verified answers |GET…
4. When caring for a A. Airway patency Remember ABCs with
patient who is 3 hours prioritization. Airway patency is always the highest
postoperative priority and is essential for a patient undergoing
laryngectomy, the nurse's surgery surrounding the upper respiratory system.
highest priority
assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and
heart rate
5. When initially teaching A. ColaWhen learning the supraglottic swallow, it
a patient the supraglottic may be helpful to start with carbonated beverages
swallow following a because the effervescence provides clues about
radical neck dissection, the liquid's position. Thin, watery fluids should be
with which of the avoided because they are difficult to swallow and
following foods should increase the risk of aspiration. Nonpourable pureed
the nurse begin? foods, such as applesauce, would decrease the risk
A. Cola of aspiration, but carbonated beverages are the
B. Applesauce better choice to start with.
C. French fries
D. White grape juice
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, 4/23/25, 3:13 PM HESI MED SURG v1 2025|Actual Exam Test(MULTIPLE CHOICES) and (RATIONALES) questions and verified answers |GET…
6. The nurse is caring for A. Hyperthermia related to infectious illness
a patient admitted to the Because the patient has spiked a temperature and
hospital with pneumonia. has a diagnosis of pneumonia, the logical nursing
Upon assessment, the diagnosis is hyperthermia related to infectious
nurse notes a illness. There is no evidence of a chill, and her
temperature of 101.4° F, a breathing pattern is within normal limits at 20
productive cough with breaths per minute. There is no evidence of
yellow sputum and a ineffective airway clearance from the information
respiratory rate of 20. given because the patient is expectorating sputum.
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
7. Which of the following D. Basilar crackles The presence of adventitious
physical assessment breath sounds indicates that there is accumulation of
findings in a patient with secretions in the lower airways. This would be
pneumonia best supports consistent with a nursing diagnosis of ineffective
the nursing diagnosis of airway clearance because the patient is retaining
ineffective airway secretions.
clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish
sputum
D. Basilar crackles
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