HESI MED SURG 1 FINAL EXAM TEST BANK LATEST
2025 ACTUAL EXAM 350 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
The nurseassessesa patientwith shortnessof breathfor evidenceof long-standinghypoxemiaby inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratorypattern
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 degrees
to 180
or more,usuallyaccompaniedby an increasein thedepth,bulk, and sponginessof theend of the finger.
2. The nurseis caring for a patientwith COPD and pneumoniawhohas an orderfor arterialbloodgases 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
thepuncturesitefor 5 minutes bytheclock to besurethatbleedinghas 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 nursenoticesclearnasaldrainagein a patientnewlyadmittedwith facialtrauma,including a nasal
fracture. The nurse should:
A. testthedrainagefor thepresenceof glucose.
B. suctionthenoseto maintainairwayclearance.
C. documentthefindingsand continuemonitoring.
,D. apply a drip pad and reassure the patient this is normal.
- answer-A. test the drainage for the presence
of
glucose.Clear nasaldrainagesuggestsleakageof cerebrospinalfluid (CSF). The drainage should be tested for
the presence of glucose, which would indicate the presence of CSF.
,4. When caring for a patientwho is 3 hourspostoperativelaryngectomy,thenurse'shighestpriority
assessment would be:
A. Airway patency
B. Patientcomfort
C. Incisional drainage
D. Blood pressureand heartrate- answer-A. Airway patencyRememberABCs 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 teachinga patientthesupraglotticswallowfollowinga radicalneck 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,
fluids
watery
shouldbe avoidedbecausetheyaredifficultto swallowand increasetherisk 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
notes
nurse
a
temperatureof 101.4°F, a productivecoughwith yellowsputumand a respiratoryrateof
20. Which of thefollowingnursing diagnosisis mostappropriatebaseduponthis assessment?A. Hyperthermia
related to infectious illness
B. Ineffectivethermoregulationrelatedto chilling
C. Ineffectivebreathingpatternrelatedto pneumonia
D. Ineffectiveairwayclearancerelatedto thick secretions- answer-A. Hyperthermiarelatedto 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 thefollowingphysicalassessmentfindings in a patientwithpneumoniabestsupportsthe nursing
diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratoryrateof 28
C. Presenceof greenishsputum
D. Basilarcrackles- answer-D. BasilarcracklesThe presenceof adventitiousbreathsoundsindicatesthat 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 thefollowingclinical manifestationswouldthenurseexpectto find during assessmentof a patient
admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine cracklesin all lobeson auscultation
C. Increasedvocal fremituson palpationD. Vesicularbreathsoundsin 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.
9. Which of thefollowingnursing interventionsis of thehighestpriority in helpinga patientexpectorate thick
secretions related to pneumonia?
A. Humidify theoxygenas able
B. Increasefluid intaketo 3L/dayif tolerated.
C. Administercoughsuppressantq4hr.
D. Teach patient to splint the affected area.
- answer-B. Increase fluid intake to 3L/day if tolerated. Although
severalinterventionsmay helpthepatientexpectoratemucus,thehighestpriority shouldbe on increasing fluid
intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the
oxygen is also helpful, but is not the primary intervention. Teaching the patient tothesplint
affectedareamay
also be helpful,but doesnot liquefythe secretions so that they can be removed.
10. During dischargeteachingfor a 65-year-old patientwith emphysemaand pneumonia,whichof the
following vaccines should the nurse recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
2025 ACTUAL EXAM 350 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
The nurseassessesa patientwith shortnessof breathfor evidenceof long-standinghypoxemiaby inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratorypattern
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 degrees
to 180
or more,usuallyaccompaniedby an increasein thedepth,bulk, and sponginessof theend of the finger.
2. The nurseis caring for a patientwith COPD and pneumoniawhohas an orderfor arterialbloodgases 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
thepuncturesitefor 5 minutes bytheclock to besurethatbleedinghas 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 nursenoticesclearnasaldrainagein a patientnewlyadmittedwith facialtrauma,including a nasal
fracture. The nurse should:
A. testthedrainagefor thepresenceof glucose.
B. suctionthenoseto maintainairwayclearance.
C. documentthefindingsand continuemonitoring.
,D. apply a drip pad and reassure the patient this is normal.
- answer-A. test the drainage for the presence
of
glucose.Clear nasaldrainagesuggestsleakageof cerebrospinalfluid (CSF). The drainage should be tested for
the presence of glucose, which would indicate the presence of CSF.
,4. When caring for a patientwho is 3 hourspostoperativelaryngectomy,thenurse'shighestpriority
assessment would be:
A. Airway patency
B. Patientcomfort
C. Incisional drainage
D. Blood pressureand heartrate- answer-A. Airway patencyRememberABCs 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 teachinga patientthesupraglotticswallowfollowinga radicalneck 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,
fluids
watery
shouldbe avoidedbecausetheyaredifficultto swallowand increasetherisk 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
notes
nurse
a
temperatureof 101.4°F, a productivecoughwith yellowsputumand a respiratoryrateof
20. Which of thefollowingnursing diagnosisis mostappropriatebaseduponthis assessment?A. Hyperthermia
related to infectious illness
B. Ineffectivethermoregulationrelatedto chilling
C. Ineffectivebreathingpatternrelatedto pneumonia
D. Ineffectiveairwayclearancerelatedto thick secretions- answer-A. Hyperthermiarelatedto 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 thefollowingphysicalassessmentfindings in a patientwithpneumoniabestsupportsthe nursing
diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratoryrateof 28
C. Presenceof greenishsputum
D. Basilarcrackles- answer-D. BasilarcracklesThe presenceof adventitiousbreathsoundsindicatesthat 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 thefollowingclinical manifestationswouldthenurseexpectto find during assessmentof a patient
admitted with pneumococcal pneumonia? A. Hyperresonance on percussion
B. Fine cracklesin all lobeson auscultation
C. Increasedvocal fremituson palpationD. Vesicularbreathsoundsin 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.
9. Which of thefollowingnursing interventionsis of thehighestpriority in helpinga patientexpectorate thick
secretions related to pneumonia?
A. Humidify theoxygenas able
B. Increasefluid intaketo 3L/dayif tolerated.
C. Administercoughsuppressantq4hr.
D. Teach patient to splint the affected area.
- answer-B. Increase fluid intake to 3L/day if tolerated. Although
severalinterventionsmay helpthepatientexpectoratemucus,thehighestpriority shouldbe on increasing fluid
intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the
oxygen is also helpful, but is not the primary intervention. Teaching the patient tothesplint
affectedareamay
also be helpful,but doesnot liquefythe secretions so that they can be removed.
10. During dischargeteachingfor a 65-year-old patientwith emphysemaand pneumonia,whichof the
following vaccines should the nurse recommend the patient receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
