MED-SURG HESI EXIT TEST BANK
NEWEST / HESI MED-SURG EXIT EXAM
COMPLETE 230 QUESTIO NS AND
CORRECT DETAILED ANS WERS
(VERIFIED ANSWERS) |ALREADY
GRADED A+
Question : The nurse assesses a patient with shortness of
breath for evidence of long-standing hypoxemia by
inspecting:
- Chest excursion
- Spinal curvatures
- The respiratory pattern
- The fingernail and its base
Correct Answer: 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.
Question : 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?
- 2 minutes
- 5 minutes
- 10 minutes
- 15 minutes
Correct Answer: 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.
Question : The nurse notices clear nasal drainage in a patient
newly admitted with facial trauma, including a nasal fracture.
The nurse should:
- test the drainage for the presence of glucose.
- suction the nose to maintain airway clearance.
- document the findings and continue monitoring.
- apply a drip pad and reassure the patient this is normal.
Correct Answer: 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.
Question : When caring for a patient who is 3 hours
postoperative laryngectomy, the nurse's highest priority
assessment would be:
- Airway patency
- Patient comfort
- Incisional drainage
- Blood pressure and heart rate
Correct Answer: 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.
Question : When initially teaching a patient the supraglottic
swallow following a radical neck dissection, with which of the following foods should the nurse begin?
- Cola
- Applesauce
- French fries
- White grape juice
Correct Answer: 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.
Question : 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?
- Hyperthermia related to infectious illness
- Ineffective thermoregulation related to chilling
- Ineffective breathing pattern related to pneumonia
- Ineffective airway clearance related to thick secretions
Correct Answer: 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.
Question : Which of the following physical assessment
findings in a patient with pneumonia best supports the nursing diagnosis of ineffective airway clearance?
- Oxygen saturation of 85%