HESI 2025 MED SURG || MED SURG HESI
ELABORATED ANSWERS ||
GUARANTEED A+
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 .- .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 .- .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. .- .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 .- .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 .- .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 .- .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 .- .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 .- .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.
ELABORATED ANSWERS ||
GUARANTEED A+
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 .- .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 .- .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. .- .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 .- .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 .- .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 .- .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 .- .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 .- .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.
