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HESI Med Surg 1 (Solved) Questions & Answers
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HESI Med Surg 1 (Solved) Questions &Answers
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 Correct Ans - 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 Correct Ans - 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. Correct Ans -
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 Correct Ans - 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 Correct Ans - 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 Correct Ans -
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 Correct Ans - 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 Correct Ans - 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 the following nursing interventions is of the highest priority in
helping a patient expectorate thick secretions related to pneumonia?
A. Humidify the oxygen as able
B. Increase fluid intake to 3L/day if tolerated.
C. Administer cough suppressant q4hr.
D. Teach patient to splint the affected area. Correct Ans - B. Increase
fluid intake to 3L/day if tolerated. Although several interventions may help
the patient expectorate mucus, the highest priority should be 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 to splint the affected area
may also be helpful, but does not liquefy the secretions so that they can be
removed.
10. During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the
patient receive?
, A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) Correct Ans - C. Pneumococcal The
pneumococcal vaccine is important for patients with a history of heart or lung
disease, recovering from a severe illness, age 65 or over, or living in a long-
term care facility.
11. 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 Ans - 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.
12. 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
D. Sputum culture and sensitivity Correct Ans - 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
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