MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
MED SURG HESI V1 -V2 EXAM ACTUAL EXAM COMPLETE
VERIFIED QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED RATIONALES) |ALREADY GRADED A+
1. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the
following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune
system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray
to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - Correct Answer-D. "I should continue to do deep-breathing and
coughing exercises for at least 6 weeks." It is important for the patient to continue
with coughing and deep breathing exercises for 6 to 8 weeks until all of the
infection has cleared from the lungs. A patient should seek medical treatment for
upper respiratory infections that persist for more than 7 days. Increased fluid
intake, not caloric intake, is required to liquefy secretions. Home O2 is not a
requirement unless the patient's oxygenation saturation is below normal.
2. After admitting a patient to the medical unit with a diagnosis of pneumonia, the
nurse will verify that which of the following physician orders have been completed
before administering a dose of cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
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, MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
D. Sputum culture and sensitivity - Correct Answer-D. Sputum culture and
sensitivityThe nurse should ensure that the sputum for culture and sensitivity was
sent to the laboratory before administering the cefotetan. It is important that the
organisms are correctly identified (by the culture) before their numbers are
affected by the antibiotic; the test will also determine whether the proper
antibiotic has been ordered (sensitivity testing). Although antibiotic administration
should not be unduly delayed while waiting for the patient to expectorate sputum,
all of the other options will not be affected by the administration of antibiotics.
3. 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" - Correct Answer-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.
4. 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.
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, MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
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. - Correct Answer-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.
5. 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 - Correct Answer-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.
6. 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.
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, MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
B. Move the oximetry probe from the finger to the earlobe for more accurate
monitoring during 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. - Correct Answer-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.
7. 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 - Correct Answer-
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.
8. In the case of pulmonary embolus from deep vein thrombosis, which of the
following actions should the nurse take first?
A. Notify the physician.
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MED SURG HESI V1 -V2 EXAM ACTUAL EXAM COMPLETE
VERIFIED QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED RATIONALES) |ALREADY GRADED A+
1. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the
following measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune
system well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray
to reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - Correct Answer-D. "I should continue to do deep-breathing and
coughing exercises for at least 6 weeks." It is important for the patient to continue
with coughing and deep breathing exercises for 6 to 8 weeks until all of the
infection has cleared from the lungs. A patient should seek medical treatment for
upper respiratory infections that persist for more than 7 days. Increased fluid
intake, not caloric intake, is required to liquefy secretions. Home O2 is not a
requirement unless the patient's oxygenation saturation is below normal.
2. After admitting a patient to the medical unit with a diagnosis of pneumonia, the
nurse will verify that which of the following physician orders have been completed
before administering a dose of cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
1|Page
, MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
D. Sputum culture and sensitivity - Correct Answer-D. Sputum culture and
sensitivityThe nurse should ensure that the sputum for culture and sensitivity was
sent to the laboratory before administering the cefotetan. It is important that the
organisms are correctly identified (by the culture) before their numbers are
affected by the antibiotic; the test will also determine whether the proper
antibiotic has been ordered (sensitivity testing). Although antibiotic administration
should not be unduly delayed while waiting for the patient to expectorate sputum,
all of the other options will not be affected by the administration of antibiotics.
3. 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" - Correct Answer-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.
4. 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.
2|Page
, MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
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. - Correct Answer-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.
5. 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 - Correct Answer-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.
6. 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.
3|Page
, MED SURG HESI V1 -V2 EXAM ACTUAL EXAM
B. Move the oximetry probe from the finger to the earlobe for more accurate
monitoring during 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. - Correct Answer-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.
7. 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 - Correct Answer-
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.
8. In the case of pulmonary embolus from deep vein thrombosis, which of the
following actions should the nurse take first?
A. Notify the physician.
4|Page
