HESI MED SURG ACTUAL
EXAM 2024 [GRADED A+].
NEWEST 2024
1. The nurse assesses a patient with shortness of breath for evidence of
long-standing
... [Show More] hypoxemia by inspecting:
A. Chest excursion
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its base - 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 - 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. - 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 - 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 - 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 - 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 - 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 - 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. - 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) - 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." [Show Less]