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HESI Med Surg QUESTIONS AND ANSWERS .
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HESI Med Surg QUESTIONS ANDANSWERS 2023 2024
1. 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: 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. 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: 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. 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.: 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. 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: 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. 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: 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. 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: 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. 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: 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. 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: 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. 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.: 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. 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): 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. 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
infec-tions."
D. "I should continue to do deep-breathing and coughing exercises for at
least 6 weeks.": 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. 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: 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
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