HESI Critical Care RN Exit Exam 1 QUESTIONS
AND CORRECT ANSWERS (100% CORRECT
ANSWERS) WITH RATIONALES/
GUARANTEED PASS GRADED A+
A nurse is preparing to care for a preschool-age child with sickle cell anemia who
is experiencing vasoocclusive pain. Which method of assessing the degree of
pain the child is experiencing is most appropriate?
Asking the child to describe the intensity of the pain
Asking the child to use a numeric rating scale of 0 to 100
Asking the child whether the patient-controlled analgesia (PCA) pump is
relieving the pain
A+ TEST BANK 1
, HESI Critical Care RN Exit Exam
Asking the child to point to the face on a spectrum ranging from smiling to very
sad, that best describes the pain –
Correct Answer :Asking the child to point to the face on a spectrum ranging
from smiling to very sad, that best describes the pain
Rationale: A client of preschool age has the cognitive ability to recognize happy
and sad faces and to correlate them with the level of pain he or she is
experiencing. It may be too complicated for some preschoolers to come up with
words to describe varying intensities of pain. Many preschool children are not
yet able to count to 100 or to understand the value of numbers in relation to
other numbers. A child of preschool age is too young to control a PCA pump.
A school nurse observing a child diagnosed with Down syndrome is participating
in a physical education class and notes that the child is experiencing a
diminution in motor abilities. The nurse asks to see the child and conducts an
assessment, during which the child complains of neck pain and loss of bladder
control. What is the appropriate action by the nurse?
Contacting the child's primary health care provider to report the findings
Administering acetaminophen to the child to relieve the pain
Asking that the child not attend the physical education class until the neck pain
has subsided
Teaching the child how to use peripads to prevent embarrassment resulting
from loss of bladder control –
A+ TEST BANK 2
, HESI Critical Care RN Exit Exam
Correct Answer :Contacting the child's primary health care provider to report the
findings
Rationale:
Children with Down syndrome who participate in sports that may involve stress
on the neck should be evaluated radiologically for atlantoaxial instability.
Signs/symptoms of the disorder include neck pain, weakness, and torticollis.
Affected children are at risk for spinal cord compression. Signs/symptoms of
spinal cord compression include persistent neck pain, loss of established motor
skills and bladder or bowel control, and changes in sensation. If any of these
signs/symptoms are noted, it must be reported immediately to the primary
health care provider. Administering acetaminophen to relieve the pain and not
allowing the child to attend physical education class until the pain has subsided
are inappropriate actions that will delay necessary interventions. Teaching the
child to use peripads to prevent embarrassment resulting from loss of bladder
control may be appropriate in certain scenarios, but in this situation the child is
exhibiting signs/symptoms of spinal cord compression, requiring immediate
intervention.
A client is taking gentamicin sulfate for the treatment of pelvic inflammatory
disease. What does the nurse ask the client during assessment for adverse
effects of the medication?
"When was your last bowel movement?"
"When was your last menstrual period?"
"Are you having any difficulty hearing?"
"Are you having any difficulty breathing?" –
A+ TEST BANK 3
, HESI Critical Care RN Exit Exam
Correct Answer :"Are you having any difficulty hearing?"
Rationale:
Serious adverse reactions to aminoglycosides include ototoxicity and
nephrotoxicity. Gentamicin sulfate is an aminoglycoside. It inhibits bacterial
protein synthesis and has a bactericidal effect. The nurse must assess the client
for changes in hearing, balance, and urine output. The remaining assessment
questions are not associated with the adverse effects of this medication.
A nurse is providing instruction about insulin therapy and its administration to an
adolescent client who has just been found to have diabetes mellitus. Which
statement by the client indicates a need for further instruction?
"It's important to rotate injection sites."
"I need to store the insulin in a cool, dry place."
"I need to keep any unopened bottles of insulin in the freezer."
"I need to check the expiration date on the insulin before I use it." –
Correct Answer :"I need to keep any unopened bottles of insulin in the freezer."
Rationale:
A+ TEST BANK 4