HESI RN Critical Care Exit Exam Prep - 7th
Edition Test Bank with 600+ Questions &
Rationales by Sandra Upchurch and Mary Ann
Hogan - Pass Your Exam on the First Attempt
and Avoid Resits
A. Compress the chest once between the nipples
with two fingers. B. Note any obstruction or absence
of breathing. C. Deliver five backslaps between the
shoulder blades. D. Place the infant over the
nurse's arm. E. Perform a blind finger sweep. -
ANSWER//B, C, D Rationale: The fingers are
placed at the same location on an infant as chest
compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps.
Blind sweeps are not used as this action may push
the object deeper into the throat. The remaining
steps are correct. Which fluid will the nurse select to
administer with the prescribed blood transfusion? A.
5% Dextrose and water B. Normal saline C.
Lactated Ringers solution D. 5% Dextrose and
lactated ringers - ANSWER//B Rationale: Normal
saline solution is the only solution that is compatible
with blood. When assisting a client from the bed to
a chair, which procedure is best for the nurse to
follow? A. Place the chair parallel to the bed, with its
back toward the head of the bed and assist the
client in moving to the chair. B. With the nurse's feet
spread apart and knees aligned with the client's
knees, stand and pivot the client into the chair. C.
Assist the client to a standing position by gently
lifting upward, underneath the axillae. D. Stand
,beside the client, place the client's arms around the
nurse's neck, and gently move the client to the chair.
- ANSWER//B Rationale: Option B describes the
correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the
client's knees when assisting to a standing position.
The chair should be placed at a 45-degree angle to
the bed, with the back of the chair toward the head
of the bed. Clients should never be lifted under the
axillae; this could damage nerves and strain the
nurse's back. The client should be instructed to use
the arms of the chair and should never place his or
her arms around the nurse's neck; this places
undue stress on the nurse's neck and back and
increases the risk for a fall. How many mL will the
nurse document on the client's intake and output
record from the items listed? _____ mL 1200 mL
water 4 ounce container of gelatin 8 ounces of
orange juice 355 mL can of soda1 cup of soup -
ANSWER//Answer: 2155 Rationale: 1200 + 240 (8
oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155 The
nurse observes a UAP taking a client's blood
pressure in the lower extremity. Which observation
of this procedure requires the nurse to intervene
with the UAP's approach? A. The cuff wraps around
the girth of the leg. B. The UAP auscultates the
popliteal pulse with the cuff on the lower leg. C. The
client is placed in a prone position. D. The systolic
reading is 20 mm Hg higher than the blood pressure
in the client's arm. - ANSWER//B Rationale: When
obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for
auscultation when the blood pressure cuff is applied
,around the thigh. The nurse should intervene with
the UAP who has applied the cuff on the lower leg.
Option A ensures an accurate assessment, and
option C provides the best access to the artery.
Systolic pressure in the popliteal artery is usually 10
to 40 mm Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old
reports to the nurse that her child is often awake
until midnight playing and is then very difficult to
awaken in the morning for school. Which
assessment data should the nurse obtain in
response to the mother's concern? A. The
occurrence of any episodes of sleep apnea B. The
child's blood pressure, pulse, and respirations C.
Length of rapid eye movement (REM) sleep that the
child is experiencing D. Description of the family's
home environment - ANSWER//D Rationale:
School-age children often resist bedtime. The nurse
should begin by assessing the environment of the
home to determine factors that may not be
conducive to the establishment of bedtime rituals
that promote sleep. Option A often causes daytime
fatigue rather than resistance to going to sleep.
Option B is unlikely to provide useful data. The
nurse cannot determine option C. The nurse
identifies a potential for infection in a client with
partial-thickness (second-degree) and full-thickness
(third-degree) burns. What action has the highest
priority in decreasing the client's risk of infection? A.
Administration of plasma expanders B. Use of
careful handwashing technique C. Application of a
topical antibacterial cream D. Limiting visitors to the
client with burns - ANSWER//B Rationale: Careful
, handwashing technique is the single most effective
intervention for the prevention of contamination to
all clients. Option A reverses the hypovolemia that
initially accompanies burn trauma but is not related
to decreasing the proliferation of infective
organisms. Options C and D are recommended by
various burn centers as possible ways to reduce the
chance of infection. Option B is a proven technique
to prevent infection. The nurse assesses a 2-year-
old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even
though the venous access site is healthy. What
should the nurse do next? A. Apply a warm
compress proximal to the site. B. Check for kinks in
the tubing and raise the IV pole. C. Adjust the tape
that stabilizes the needle. D. Flush with normal
saline and recount the drop rate. - ANSWER//B
Rationale: The nurse should first check the tubing
and height of the bag on the IV pole, which are
common factors that may slow the rate. Gravity
infusion rates are influenced by the height of the
bag, tubing clamp closure or kinks, needle size or
position, fluid viscosity, client blood pressure (crying
in the pediatric client), and infiltration. Venospasm
can slow the rate and often responds to warmth
over the vessel, but the nurse should first adjust the
IV pole height. The nurse may need to adjust the
stabilizing tape on a positional needle or flush the
venous access with normal saline, but less invasive
actions should be implemented first. The nurse
manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications
of immobility. Which action should be included in
Edition Test Bank with 600+ Questions &
Rationales by Sandra Upchurch and Mary Ann
Hogan - Pass Your Exam on the First Attempt
and Avoid Resits
A. Compress the chest once between the nipples
with two fingers. B. Note any obstruction or absence
of breathing. C. Deliver five backslaps between the
shoulder blades. D. Place the infant over the
nurse's arm. E. Perform a blind finger sweep. -
ANSWER//B, C, D Rationale: The fingers are
placed at the same location on an infant as chest
compressions for CPR; however, the nurse must
deliver five chest thrusts, after the five back slaps.
Blind sweeps are not used as this action may push
the object deeper into the throat. The remaining
steps are correct. Which fluid will the nurse select to
administer with the prescribed blood transfusion? A.
5% Dextrose and water B. Normal saline C.
Lactated Ringers solution D. 5% Dextrose and
lactated ringers - ANSWER//B Rationale: Normal
saline solution is the only solution that is compatible
with blood. When assisting a client from the bed to
a chair, which procedure is best for the nurse to
follow? A. Place the chair parallel to the bed, with its
back toward the head of the bed and assist the
client in moving to the chair. B. With the nurse's feet
spread apart and knees aligned with the client's
knees, stand and pivot the client into the chair. C.
Assist the client to a standing position by gently
lifting upward, underneath the axillae. D. Stand
,beside the client, place the client's arms around the
nurse's neck, and gently move the client to the chair.
- ANSWER//B Rationale: Option B describes the
correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the
client's knees when assisting to a standing position.
The chair should be placed at a 45-degree angle to
the bed, with the back of the chair toward the head
of the bed. Clients should never be lifted under the
axillae; this could damage nerves and strain the
nurse's back. The client should be instructed to use
the arms of the chair and should never place his or
her arms around the nurse's neck; this places
undue stress on the nurse's neck and back and
increases the risk for a fall. How many mL will the
nurse document on the client's intake and output
record from the items listed? _____ mL 1200 mL
water 4 ounce container of gelatin 8 ounces of
orange juice 355 mL can of soda1 cup of soup -
ANSWER//Answer: 2155 Rationale: 1200 + 240 (8
oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155 The
nurse observes a UAP taking a client's blood
pressure in the lower extremity. Which observation
of this procedure requires the nurse to intervene
with the UAP's approach? A. The cuff wraps around
the girth of the leg. B. The UAP auscultates the
popliteal pulse with the cuff on the lower leg. C. The
client is placed in a prone position. D. The systolic
reading is 20 mm Hg higher than the blood pressure
in the client's arm. - ANSWER//B Rationale: When
obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for
auscultation when the blood pressure cuff is applied
,around the thigh. The nurse should intervene with
the UAP who has applied the cuff on the lower leg.
Option A ensures an accurate assessment, and
option C provides the best access to the artery.
Systolic pressure in the popliteal artery is usually 10
to 40 mm Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old
reports to the nurse that her child is often awake
until midnight playing and is then very difficult to
awaken in the morning for school. Which
assessment data should the nurse obtain in
response to the mother's concern? A. The
occurrence of any episodes of sleep apnea B. The
child's blood pressure, pulse, and respirations C.
Length of rapid eye movement (REM) sleep that the
child is experiencing D. Description of the family's
home environment - ANSWER//D Rationale:
School-age children often resist bedtime. The nurse
should begin by assessing the environment of the
home to determine factors that may not be
conducive to the establishment of bedtime rituals
that promote sleep. Option A often causes daytime
fatigue rather than resistance to going to sleep.
Option B is unlikely to provide useful data. The
nurse cannot determine option C. The nurse
identifies a potential for infection in a client with
partial-thickness (second-degree) and full-thickness
(third-degree) burns. What action has the highest
priority in decreasing the client's risk of infection? A.
Administration of plasma expanders B. Use of
careful handwashing technique C. Application of a
topical antibacterial cream D. Limiting visitors to the
client with burns - ANSWER//B Rationale: Careful
, handwashing technique is the single most effective
intervention for the prevention of contamination to
all clients. Option A reverses the hypovolemia that
initially accompanies burn trauma but is not related
to decreasing the proliferation of infective
organisms. Options C and D are recommended by
various burn centers as possible ways to reduce the
chance of infection. Option B is a proven technique
to prevent infection. The nurse assesses a 2-year-
old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even
though the venous access site is healthy. What
should the nurse do next? A. Apply a warm
compress proximal to the site. B. Check for kinks in
the tubing and raise the IV pole. C. Adjust the tape
that stabilizes the needle. D. Flush with normal
saline and recount the drop rate. - ANSWER//B
Rationale: The nurse should first check the tubing
and height of the bag on the IV pole, which are
common factors that may slow the rate. Gravity
infusion rates are influenced by the height of the
bag, tubing clamp closure or kinks, needle size or
position, fluid viscosity, client blood pressure (crying
in the pediatric client), and infiltration. Venospasm
can slow the rate and often responds to warmth
over the vessel, but the nurse should first adjust the
IV pole height. The nurse may need to adjust the
stabilizing tape on a positional needle or flush the
venous access with normal saline, but less invasive
actions should be implemented first. The nurse
manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications
of immobility. Which action should be included in
