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 WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+

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.