MED SURG RN HESI EXIT EXAM 2024 VERSION 1
AND 2 /HESI RN MED SURG EXIT EXAM VERSION
1 AND 2 COMPLETE ALL 55 QUESTIONS AND
CORRECT DETAILED ANSWERS
... [Show More] WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
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 - ...ANSWER...D.
RATIONALE: 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 - ...ANSWER...B.
RATIONALE: 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. - ...ANSWER...A.
RATIONALE: 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 - ...ANSWER...A.
RATIONALE: 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 - ...ANSWER...A.
RATIONALE: 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 - ...ANSWER...A. RATIONALE: 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 - ...ANSWER...D.
RATIONALE: 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 - ...ANSWER...C. Increased
vocal fremitus on palpation.
RATIONALE: 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. -
...ANSWER...B. Increase fluid intake to 3L/day if
tolerated.
RATIONALE: 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) - ...ANSWER...C.
Pneumococcal
RATIONALE: 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." -
...ANSWER...D.
RATIONALE: "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 [Show Less]