10/19/24, 4:12 AM HESI 101- MED SURGE HESI RN 2 LATEST VERSIONS 2024-2025 EACH VERSION WITH 55 QUESTIONS AND CORRECT A…
HESI 101- MED SURGE HESI RN 2 LATEST
VERSIONS 2024-2025 EACH VERSION WITH 55
QUESTIONS AND CORRECT ANSWERS|AGRADE
Terms in this set (201)
The nurse assesses a D. The fingernail and its base Clubbing, a sign of long-
patient with shortness of standing hypoxemia, is evidenced by an increase in
breath for evidence of the angle between the base of the nail and the
long-standing hypoxemia fingernail to 180 degrees or more, usually
by inspecting: accompanied by an increase in the depth, bulk, and
A. Chest excursion sponginess of the end of the finger.
B. Spinal curvatures
C. The respiratory pattern
D. The fingernail and its
base
2. The nurse is caring for a B. 5 minutes Following obtaining an arterial blood gas,
patient with COPD and the nurse should hold pressure on the puncture site
pneumonia who has an for 5 minutes by the clock to be sure that bleeding
order for arterial blood has stopped. An artery is an elastic vessel under
gases to be drawn. Which higher pressure than veins, and significant blood loss
of the following is the or hematoma formation could occur if the time is
minimum length of time insufficient.
the nurse should plan to
hold pressure on the
puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes
,10/19/24, 4:12 AM HESI 101- MED SURGE HESI RN 2 LATEST VERSIONS 2024-2025 EACH VERSION WITH 55 QUESTIONS AND CORRECT A…
3. The nurse notices clear A. test the drainage for the presence of glucose. Clear
nasal drainage in a patient nasal drainage suggests leakage of cerebrospinal
newly admitted with facial fluid (CSF). The drainage should be tested for the
trauma, including a nasal presence of glucose, which would indicate the
fracture. The nurse should: presence of CSF.
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.
4. When caring for a A. Airway patency Remember ABCs with prioritization.
patient who is 3 hours Airway patency is always the highest priority and is
postoperative essential for a patient undergoing surgery
laryngectomy, the nurse's surrounding the upper respiratory system.
highest priority
assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and
heart rate
5. When initially teaching a A. ColaWhen learning the supraglottic swallow, it may
patient the supraglottic be helpful to start with carbonated beverages
swallow following a because the effervescence provides clues about the
radical neck dissection, liquid's position. Thin, watery fluids should be avoided
with which of the because they are difficult to swallow and increase the
following foods should risk of aspiration. Nonpourable pureed foods, such as
the nurse begin? applesauce, would decrease the risk of aspiration, but
A. Cola carbonated beverages are the better choice to start
B. Applesauce with.
C. French fries
D. White grape juice
,10/19/24, 4:12 AM HESI 101- MED SURGE HESI RN 2 LATEST VERSIONS 2024-2025 EACH VERSION WITH 55 QUESTIONS AND CORRECT A…
6. The nurse is caring for a A. Hyperthermia related to infectious illness Because
patient admitted to the the patient has spiked a temperature and has a
hospital with pneumonia. diagnosis of pneumonia, the logical nursing diagnosis
Upon assessment, the is hyperthermia related to infectious illness. There is
nurse notes a temperature no evidence of a chill, and her breathing pattern is
of 101.4° F, a productive within normal limits at 20 breaths per minute. There is
cough with yellow sputum no evidence of ineffective airway clearance from the
and a respiratory rate of information given because the patient is
20. Which of the following expectorating sputum.
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
7. Which of the following D. Basilar crackles The presence of adventitious
physical assessment breath sounds indicates that there is accumulation of
findings in a patient with secretions in the lower airways. This would be
pneumonia best supports consistent with a nursing diagnosis of ineffective
the nursing diagnosis of airway clearance because the patient is retaining
ineffective airway secretions.
clearance? A. Oxygen
saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish
sputum
D. Basilar crackles
, 10/19/24, 4:12 AM HESI 101- MED SURGE HESI RN 2 LATEST VERSIONS 2024-2025 EACH VERSION WITH 55 QUESTIONS AND CORRECT A…
8. Which of the following C. Increased vocal fremitus on palpation. A typical
clinical manifestations physical examination finding for a patient with
would the nurse expect to pneumonia is increased vocal fremitus on palpation.
find during assessment of Other signs of pulmonary consolidation include
a patient admitted with dullness to percussion, bronchial breath sounds, and
pneumococcal crackles in the affected area.
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
9. Which of the following B. Increase fluid intake to 3L/day if tolerated. Although
nursing interventions is of several interventions may help the patient
the highest priority in expectorate mucus, the highest priority should be on
helping a patient increasing fluid intake, which will liquefy the
expectorate thick secretions so that the patient can expectorate them
secretions related to more easily. Humidifying the oxygen is also helpful,
pneumonia? but is not the primary intervention. Teaching the
A. Humidify the oxygen as patient to splint the affected area may also be helpful,
able but does not liquefy the secretions so that they can
B. Increase fluid intake to be removed.
3L/day if tolerated.
C. Administer cough
suppressant q4hr.
D. Teach patient to splint
the affected area.
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