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 ineffectiv [Show Less]