HESI Med Surg III Exam Questions and Answers 2023

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HESI Med Surg III Exam Questions and Answers 2023 (Verified Answers)

• List four common symptoms of pneumonia the nurse might note on physi-

cal examination: - Tachypnea, shallow respirations with use of accessory muscles

• abrupt onset of fever with shaking and chills (not reliable in older adults)
• productive cough with pleuritic pain
• rapid, bounding pulse

• State four nursing interventions for assisting the client to cough produc-

tively: - deep breathing q2 hours (may use incentive spirometer)

• use humidity to loosen secretions (may be used with O2)
• suctioning the airway if necessary, also helps with coughing
• chest physiotherapy

-increase fluids to 3L/day

• What symptoms of pneumonia might the nurse expect to see in an older

client?: - confusion

• lethargy/malaise
• anorexia
• rapid respiratory rate
• tachycardia 1 / 3

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4. How does the nurse prevent hypoxia when suctioning?: oxygenate with 100%

O2 for 1-2 minutes before and after suctioning

• During mechanical ventilation, what are three major nursing interventions?-

: - verify that the alarms are on

• maintain settings, and check often to ensure that they are specifically set as

prescribed by the HCP

• verify functioning of ventilator at least q4 hours

-keep airway clear by coughing and suctioning

• When examining a client with emphysema, what physical findings is the

nurse most likely to see?: - bronchospasm and dyspnea

• change in breathing pattern
• over inflation of lungs... barrel chest
• generalized cyanosis
• either dry or productive cough
• higher CO2 than average
• low O2, usually between 90-92%
• decreased breath sounds
• coarse crackles in lungs that tend to disappear after coughing
• orthopnea
• poor nutrition, weight loss
• activity intolerance

-anxiety from not being able to breath 2 / 3

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7. What is the most common risk factor associated with lung cancer?: cigarette

smoking/marijuana

8. describe why preop care is important for a pt going for a laryngectomy: -

involve family and client in manipulation of trach equipment before surgery

• plan acceptable communication methods
• refer to speech pathologist
• discuss rehab program

9. List 5 nursing interventions after chest tube insertion.: - keep all tubing

loosely coiled below chest level, ensure connections are tight and taped

• keep water seal and suction control at appropriate levels
• monitor fluid drainage and mark times of measurement and the fluid level
• observe for bubbling in water seal chamber
• monitor clients clinical status
• check position of chest drainage system
• encourage client to deep breath periodically
• do not empty collection chamber container of chest tube, replace whole unit when

full

• do not strip or milk chest tubes
• chest tubes are not clamped, if drainage system breaks, place distal end of tube

in sterile water as an emergency water seal

• maintain dry occlusive dressing

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