HESI Med Surg Questions And Answers
2022
The nurse assesses a patient with shortness of breath for evidence of long-standing
hypoxemia by
... [Show More] 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."
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." - 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 - 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 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.
13. 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" - ANS- 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.
14. 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.
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. - ANS- 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.
15. 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 - ANS- 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.
16. 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.
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. - ANS- 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.
17. 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 - ANS- 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.
18. In the case of pulmonary embolus from deep vein thrombosis, which of the
following actions should the nurse take first?
A. Notify the physician.
B. Administer a nitroglycerin tablet sublingually.
C. Conduct a thorough assessment of the chest pain.
D. Sit the patient up in bed as tolerated and apply oxygen. - ANS- D. Sit the patient
up in bed as tolerated and apply oxygen.The patient's clinical picture is consistent
with pulmonary embolus, and the first action the nurse takes should be to assist the
patient. For this reason, the nurse should sit the patient up as tolerated and apply
oxygen before notifying the physician.
19. The nurse is caring for a postoperative patient with sudden onset of respiratory
distress. The physician orders a STAT ventilation-perfusion scan. Which of the
following explanations should the nurse provide to the patient about the procedure?
A. This test involves injection of a radioisotope to outline the blood vessels in the
lungs, followed by inhalation of a radioisotope gas.
B. This test will use special technology to examine cross sections of the chest with
use of a contrast dye.
C. This test will use magnetic fields to produce images of the lungs and chest. D.
This test involves injecting contrast dye into a blood vessel to outline the blood
vessels of the lungs. - ANS- A. This test involves injection of a radioisotope to outline
the blood vessels in the lungs, followed by inhalation of a radioisotope gas.A
ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is
injected into the blood and the pulmonary vasculature is outlined. In the ventilation
part, the patient inhales a radioactive gas that outlines the alveoli.
20. During assessment of a 45-year-old patient with asthma, the nurse notes
wheezing and dyspnea. The nurse interprets that these symptoms are related to
which of the following pathophysiologic changes? A. Laryngospasm B.
Overdistention of the alveoli C. Narrowing of the airway D. Pulmonary edema - ANSC. Narrowing of the airwayNarrowing of the airway leads to reduced airflow, making
it difficult for the patient to breathe and producing the characteristic wheezing.
21. A 45-year-old man with asthma is brought to the emergency department by
automobile. He is short of breath and appears frightened. During the initial nursing
assessment, which of the following clinical manifestations might be present as an
early symptom during an exacerbation of asthma?
A. Anxiety
B. Cyanosis
C. Hypercapnia
D. Bradycardia - ANS- A. Anxiety An early symptom during an asthma attack is
anxiety because he is acutely aware of the inability to get sufficient air to breathe. He
will be hypoxic early on with decreased PaCO2 and increased pH as he is
hyperventilating.
22. The nurse is assigned to care for a patient who has anxiety and an exacerbation
of asthma. Which of the following is the primary reason for the nurse to carefully
inspect the chest wall of this patient?
A. Observe for signs of diaphoresis
B. Allow time to calm the patient
C. Monitor the patient for bilateral chest expansion
D. Evaluate the use of intercostal muscles - ANS- D. Evaluate the use of intercostal
muscles The nurse physically inspects the chest wall to evaluate the use of
intercostal (accessory) muscles, which gives an indication of the degree of
respiratory distress experienced by the patient.
23. Which of the following positions is most appropriate for the nurse to place a
patient experiencing an asthma exacerbation?
A. Supine
B. Lithotomy
C. High-Fowler's
D. Reverse Trendelenburg - ANS- C. High-Fowler'sThe patient experiencing an
asthma attack should be placed in high-Fowler's position to allow for optimal chest
expansion and enlist the aid of gravity during inspiration.
24. The nurse is caring for a patient with an acute exacerbation of asthma. Following
initial treatment, which of the following findings indicates to the nurse that the
patient's respiratory status is improving?
A. Wheezing becomes louder
B. Vesicular breath sounds decrease
C. Aerosol bronchodilators stimulate coughing
D. The cough remains nonproductive - ANS- A. Wheezing becomes louder The
primary problem during an exacerbation of asthma is narrowing of the airway and
subsequent diminished air exchange. As the airways begin to dilate, wheezing gets
louder because of better air exchange.
25. The nurse identifies the nursing diagnosis of activity intolerance for a patient with
asthma. The nurse assesses for which of the following etiologic factor for this nursing
diagnosis in patients with asthma?
A. Anxiety and restlessness
B. Effects of medications
C. Fear of suffocation
D. Work of breathing - ANS- D. Work of breathingWhen the patient does not have
sufficient gas exchange to engage in activity, the etiologic factor is often the work of
breathing. When patients with asthma do not have effective respirations, they use all
available energy to breathe and have little left over for purposeful activity.
26. The nurse is assigned to care for a patient in the emergency department
admitted with an exacerbation of asthma. The patient has received a β-adrenergic
bronchodilator and supplemental oxygen. If the patient's condition does not improve,
the nurse should anticipate which of the following is likely to be the next step in
treatment?
A. Pulmonary function testing
B. Systemic corticosteroids
C. Biofeedback therapy
D. Intravenous fluids - ANS- B. Systemic corticosteroids Systemic corticosteroids
speed the resolution of asthma exacerbations and are indicated if the initial response
to the β-adrenergic bronchodilator is insufficient.
27. A patient with acute exacerbation of COPD needs to receive precise amounts of
oxygen. Which of the following types of equipment should the nurse prepare to use?
A. Venturi mask
B. Partial non-rebreather mask
C. Oxygen tent
D. Nasal cannula - ANS- A. Venturi mask The Venturi mask delivers precise
concentrations of oxygen and should be selected whenever this is a priority concern.
The other methods are less precise in terms of amount of oxygen delivered.
28. While teaching a patient with asthma about the appropriate use of a peak flow
meter, the nurse instructs the patient to do which of the following?
A. Use the flow meter each morning after taking medications to evaluate their
effectiveness.
B. Empty the lungs and then inhale quickly through the mouthpiece to measure how
fast air can be inhaled.
C. Keep a record of the peak flow meter numbers if symptoms of asthma are getting
worse.
D. Increase the doses of the long-term control medication if the peak flow numbers
decrease. - ANS- C. Keep a record of the peak flow meter numbers if symptoms of
asthma are getting worse. It is important to keep track of peak flow readings daily
and when the patient's symptoms are getting worse. The patient should have specific
directions as to when to call the physician based on personal peak flow numbers.
Peak flow is measured by exhaling into the meters and should be assessed before
and after medications to evaluate their effectiveness.
29. The physician has prescribed salmeterol (Serevent) for a patient with asthma. In
reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should
provide which of the following instructions?
A. "Close lips tightly around the mouthpiece and breathe in deeply and quickly."
B. "To administer a DPI, you must use a spacer that holds the medicine so that you
can inhale it."
C. "Hold the inhaler several inches in front of your mouth and breathe in slowly,
holding the medicine as long as possible." D. "You will know you have correctly used
the DPI when you taste or sense the medicine going into your lungs." - ANS- A.
"Close lips tightly around the mouthpiece and breathe in deeply and quickly." Dry
powder inhalers do not require spacer devices. The patient should be instructed to
breathe in deeply and quickly to ensure medicine moves down deeply into lungs.
The patient may not taste or sense the medicine going into the lungs.
30. The nurse determines that a patient is experiencing common adverse effects
from the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the
following?
A. Adrenocortical dysfunction and hyperglycemia
B. Elevation of blood glucose and calcium levels
C. Oropharyngeal candidiasis and hoarseness
D. Hypertension and pulmonary edema - ANS- C. Oropharyngeal candidiasis and
hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects
from the use of inhaled corticosteroids because the medication can lead to
overgrowth of organisms and local irritation if the patient does not rinse the mouth
following each dose... [Show Less]