Critical Care HESI Practice Questions with Answers Rated A
B.) Prepare to administer desmopressin (DDAVP).
The nurse is caring for a client who presents with Neurogenic diabetes insipidus (DI) is a condition that
stroke-like symptoms. The healthcare provider reviews can occur when there is trauma to the brain such as
the client's computerized axial tomography (CAT) scan tumors or injury to the brain in particular the pituitary or
and prescribes recombinant tissue plasminogen activator hypothalamus area. DI can also occur with cerebral ede-
(rtPA) IV. Which information should the nurse obtain to ma present. The antidiuretic hormone deficiency occurs
determine if the client is a candidate for this treatment rapidly and results in polyuria, anywhere between 5- 40
now? liters of urine/24 hours. The client demonstrates signs
A.) Identify the underlying cause of this condition. and symptoms of hypovolemia. Electrolyte imbalances in-
B.) Prepare to administer desmopressin (DDAVP). clude hypernatremia, along with hypokalemia and hyper-
C.) Decrease the intravenous fluids to a maintenance calcemia when it is neurogenic etiology. Clients with neu-
rate. rogenic DI are primarily controlled through administration
D.) Replace fluid losses with D5W every shift of exogenous ADH preparations, of which desmopressin
(DDAVP) is most commonly used. Fluid output is carefully
monitored and fluids are replaced every hour.
An intubated client is in the process of being weaned ott
A.) Oxygen saturation is 91%
ventilator support. The client's baseline parameters are
C.) Heart rate is 97 beats/minute.
temperature 98.2 F (36.8 C), heart rate 88 beats/minute,
D.) Work of breathing is done by client
respirations 14 breaths/minute, blood pressure 112/78
mmHg, and oxygen saturation 94%. Which assessment
Criteria that indicates a client is tolerating weaning
findings would indicate to the nurse that the client is
ott ventilator support are respirations greater than 8
tolerating the weaning procedure? (Select all that apply.)
breaths/minute, but less than 35 breaths/minute; oxygen
A.) Oxygen saturation is 91%
saturation above 90%; heart rate that does not increase
B.) Slight nasal flaring is present.
more than 20% from baseline heart rate; most of the work
C.) Heart rate is 97 beats/minute.
of breathing is performed by the client; and no signs of
D.) Work of breathing is done by client
accessory muscles are used for breathing.
E.) Respiratory rate is 36 breaths/minute.
The nurse is assessing a burn victim who suttered destruc- B.) Superficial partial-thickness, 18% TBSA
tion of the epidermis and some of the dermis of the entire
right arm and half the length of the right leg. How should A "superficial partial-thickness" burn involves destruction
, Critical Care HESI Practice Questions with Answers Rated A
of the epidermis layer and some of the dermis layer. The
the nurse document the burn assessment findings?
total body surface area (%TBSA) is easily calculated by
A.) Superficial, 18% TBSA.
using the "rule of nines" method. In this case, involvement
B.) Superficial partial-thickness, 18% TBSA.
of one arm is calculated as 9% TBSA and one-half of a leg
C.) Deep-partial thickness, 27% TBSA.
is 9% TBSA for a combined total of 18% TBSA. A total leg
D.) Full-thickness, 27% TBSA.
involvement is calculated as 18% TBSA.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and
anemia.
he critical care nurse is providing care for a client diag- E.) Monitoring arterial blood gases and serum electrolytes
nosed clinically brain dead and identified as an organ levels.
donor. Which are the nurse's priorities in providing care?
(Select all that apply.) Once an identified organ donor has been declared clini-
A.) Sustaining a state of hypothermia. cally brain dead, the primary focus of care changes from
B.) Maintaining a normal blood pressure. preserving life to preserving organ functioning. This is
C.) Ensuring adequate oxygenation and ventilation. done by maintaining normal blood pressures, fluid lev-
D.) Treating any coagulopathy, thrombocytopenia and els, electrolytes levels, serum glucose levels, and nor-
anemia. mothermia. Mechanical ventilation is provided to maintain
E.) Monitoring arterial blood gases and serum electrolytes adequate oxygenation and normal acid-base balance. If
levels. needed, pharmaceutical support is provided for the treat-
ment of anemia, coagulopathy, thrombocytopenia, and
diabetes insipidus. Physiological changes occur to bodily
functions as the result of decreased perfusion within the
brain.
A client is admitted to the intensive care unit with he-
matemesis related to esophageal varices. Which assess- A.) Absent bowel sounds.
ment finding should the nurse identify that is the result of
an estimated blood loss at 35% of total blood volume? Massive blood loss redirects a significant amount of blood
A.) Absent bowel sounds. flow to vital organs. A client who has lost 30% to 40% of
B.) Coma.
, Critical Care HESI Practice Questions with Answers Rated A
C.) Anuria. the total blood volume will exhibit absent bowel sounds,
D.) Abdominal pain. lethargy, and increased serum potassium.
The nurse is planning care for a client admitted to the
intensive care unit with acute infected necrotizing pan-
creatitis. Which diagnostic procedure should the nurse
A.) Contrast-enhanced computed tomography (CT)
prepare the client to expect the healthcare provider to
prescribe?
Contrast-enhanced computed tomography (CT) is the
A.) Contrast-enhanced computed tomography (CT).
imaging modality of choice to evaluate peripancreatic
B.) Endoscopic retrograde cholangiopancreatography
necrosis.
(ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound.
The nurse is caring for a client admitted to the surgical
intensive care unit (ICU) after undergoing gastrointestinal
A.) Maintain patency of nasogastric tube to low intermit-
surgery. Which intervention should the nurse include in
tent suction.
the plan of care to minimize the risk for vomiting?
Gastrointestinal (GI) surgery often requires postopera-
A.) Maintain patency of nasogastric tube to low intermit-
tive nasogastric tube (NGT) insertion for low intermittent
tent suction.
suction to prevent intestinal blockage due to absent or
B.) Provide a soft, bland diet with oral liquids, such as
decreased peristalsis. The plan of care should include
diluted juices.
maintaining patency of the NGT to low intermittent suc-
C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR) solu-
tion, which empties the stomach and minimizes nausea
tion IV at 125 mL/hour.
and vomiting.
D.) Insert a rectal tube followed with progressive mobiliza-
tion techniques.
A client is admitted to the intensive care unit with he-
A.) An increase in alertness and orientation.
patic encephalopathy secondary to cirrhosis. The client
is lethargic and confused. The healthcare provider pre-
Hepatic dysfunction causes an elevated ammonia lev-
scribes lactulose. Which finding indicates a positive re-
els that cause mental status changes in clients with he-
sponse to the medication?
patic encephalopathy. Lactulose, an osmotic laxative and
A.) An increase in alertness and orientation.
colonic acidifier, pulls ammonia from the serum into the
B.) Serum ammonia level 80 mcg/dL (47 mol/L).
B.) Prepare to administer desmopressin (DDAVP).
The nurse is caring for a client who presents with Neurogenic diabetes insipidus (DI) is a condition that
stroke-like symptoms. The healthcare provider reviews can occur when there is trauma to the brain such as
the client's computerized axial tomography (CAT) scan tumors or injury to the brain in particular the pituitary or
and prescribes recombinant tissue plasminogen activator hypothalamus area. DI can also occur with cerebral ede-
(rtPA) IV. Which information should the nurse obtain to ma present. The antidiuretic hormone deficiency occurs
determine if the client is a candidate for this treatment rapidly and results in polyuria, anywhere between 5- 40
now? liters of urine/24 hours. The client demonstrates signs
A.) Identify the underlying cause of this condition. and symptoms of hypovolemia. Electrolyte imbalances in-
B.) Prepare to administer desmopressin (DDAVP). clude hypernatremia, along with hypokalemia and hyper-
C.) Decrease the intravenous fluids to a maintenance calcemia when it is neurogenic etiology. Clients with neu-
rate. rogenic DI are primarily controlled through administration
D.) Replace fluid losses with D5W every shift of exogenous ADH preparations, of which desmopressin
(DDAVP) is most commonly used. Fluid output is carefully
monitored and fluids are replaced every hour.
An intubated client is in the process of being weaned ott
A.) Oxygen saturation is 91%
ventilator support. The client's baseline parameters are
C.) Heart rate is 97 beats/minute.
temperature 98.2 F (36.8 C), heart rate 88 beats/minute,
D.) Work of breathing is done by client
respirations 14 breaths/minute, blood pressure 112/78
mmHg, and oxygen saturation 94%. Which assessment
Criteria that indicates a client is tolerating weaning
findings would indicate to the nurse that the client is
ott ventilator support are respirations greater than 8
tolerating the weaning procedure? (Select all that apply.)
breaths/minute, but less than 35 breaths/minute; oxygen
A.) Oxygen saturation is 91%
saturation above 90%; heart rate that does not increase
B.) Slight nasal flaring is present.
more than 20% from baseline heart rate; most of the work
C.) Heart rate is 97 beats/minute.
of breathing is performed by the client; and no signs of
D.) Work of breathing is done by client
accessory muscles are used for breathing.
E.) Respiratory rate is 36 breaths/minute.
The nurse is assessing a burn victim who suttered destruc- B.) Superficial partial-thickness, 18% TBSA
tion of the epidermis and some of the dermis of the entire
right arm and half the length of the right leg. How should A "superficial partial-thickness" burn involves destruction
, Critical Care HESI Practice Questions with Answers Rated A
of the epidermis layer and some of the dermis layer. The
the nurse document the burn assessment findings?
total body surface area (%TBSA) is easily calculated by
A.) Superficial, 18% TBSA.
using the "rule of nines" method. In this case, involvement
B.) Superficial partial-thickness, 18% TBSA.
of one arm is calculated as 9% TBSA and one-half of a leg
C.) Deep-partial thickness, 27% TBSA.
is 9% TBSA for a combined total of 18% TBSA. A total leg
D.) Full-thickness, 27% TBSA.
involvement is calculated as 18% TBSA.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and
anemia.
he critical care nurse is providing care for a client diag- E.) Monitoring arterial blood gases and serum electrolytes
nosed clinically brain dead and identified as an organ levels.
donor. Which are the nurse's priorities in providing care?
(Select all that apply.) Once an identified organ donor has been declared clini-
A.) Sustaining a state of hypothermia. cally brain dead, the primary focus of care changes from
B.) Maintaining a normal blood pressure. preserving life to preserving organ functioning. This is
C.) Ensuring adequate oxygenation and ventilation. done by maintaining normal blood pressures, fluid lev-
D.) Treating any coagulopathy, thrombocytopenia and els, electrolytes levels, serum glucose levels, and nor-
anemia. mothermia. Mechanical ventilation is provided to maintain
E.) Monitoring arterial blood gases and serum electrolytes adequate oxygenation and normal acid-base balance. If
levels. needed, pharmaceutical support is provided for the treat-
ment of anemia, coagulopathy, thrombocytopenia, and
diabetes insipidus. Physiological changes occur to bodily
functions as the result of decreased perfusion within the
brain.
A client is admitted to the intensive care unit with he-
matemesis related to esophageal varices. Which assess- A.) Absent bowel sounds.
ment finding should the nurse identify that is the result of
an estimated blood loss at 35% of total blood volume? Massive blood loss redirects a significant amount of blood
A.) Absent bowel sounds. flow to vital organs. A client who has lost 30% to 40% of
B.) Coma.
, Critical Care HESI Practice Questions with Answers Rated A
C.) Anuria. the total blood volume will exhibit absent bowel sounds,
D.) Abdominal pain. lethargy, and increased serum potassium.
The nurse is planning care for a client admitted to the
intensive care unit with acute infected necrotizing pan-
creatitis. Which diagnostic procedure should the nurse
A.) Contrast-enhanced computed tomography (CT)
prepare the client to expect the healthcare provider to
prescribe?
Contrast-enhanced computed tomography (CT) is the
A.) Contrast-enhanced computed tomography (CT).
imaging modality of choice to evaluate peripancreatic
B.) Endoscopic retrograde cholangiopancreatography
necrosis.
(ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound.
The nurse is caring for a client admitted to the surgical
intensive care unit (ICU) after undergoing gastrointestinal
A.) Maintain patency of nasogastric tube to low intermit-
surgery. Which intervention should the nurse include in
tent suction.
the plan of care to minimize the risk for vomiting?
Gastrointestinal (GI) surgery often requires postopera-
A.) Maintain patency of nasogastric tube to low intermit-
tive nasogastric tube (NGT) insertion for low intermittent
tent suction.
suction to prevent intestinal blockage due to absent or
B.) Provide a soft, bland diet with oral liquids, such as
decreased peristalsis. The plan of care should include
diluted juices.
maintaining patency of the NGT to low intermittent suc-
C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR) solu-
tion, which empties the stomach and minimizes nausea
tion IV at 125 mL/hour.
and vomiting.
D.) Insert a rectal tube followed with progressive mobiliza-
tion techniques.
A client is admitted to the intensive care unit with he-
A.) An increase in alertness and orientation.
patic encephalopathy secondary to cirrhosis. The client
is lethargic and confused. The healthcare provider pre-
Hepatic dysfunction causes an elevated ammonia lev-
scribes lactulose. Which finding indicates a positive re-
els that cause mental status changes in clients with he-
sponse to the medication?
patic encephalopathy. Lactulose, an osmotic laxative and
A.) An increase in alertness and orientation.
colonic acidifier, pulls ammonia from the serum into the
B.) Serum ammonia level 80 mcg/dL (47 mol/L).
