HESI Critical Care RN Exit Exam
HESI Critical Care RN Exit Exam 3 QUESTIONS
AND CORRECT ANSWERS (100% CORRECT
ANSWERS) WITH RATIONALES/
GUARANTEED PASS GRADED A+
An elderly client who requires frequent monitoring fell and fractured a hip.
Which nurse is at greatest risk for a malpractice judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing
notes.
B. The nurse assigned to care for the client who was at lunch at the time of the
fall.
C. The nurse who transferred the client to the chair when the fall occurred.
A+ TEST BANK 1
, HESI Critical Care RN Exit Exam
D. The charge nurse who completed rounds 30 minutes before the fall occurred.
–
Correct Answer :C. The nurse who transferred the client to the chair when the
fall occurred.
(The four elements of malpractice are: breach of duty owed, failure to adhere to
the recognized standard of care, direct causation of injury, and evidence of
actual injury. The hip fracture is the actual injury and the standard of care was
"frequent monitoring." (C) implies the duty was owed and the injury occurred
while the nurse was in charge of the client's care. There is no evidence of
negligence in (A, B, and D). )
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for the
nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. –
Correct Answer :B. Reassess the client's blood pressure using a larger cuff.
(The most important action is to ensure that an accurate BP reading is obtained.
The nurse should reassess the BP with the correct size cuff (B). Reassessment
A+ TEST BANK 2
, HESI Critical Care RN Exit Exam
should not be postponed (A). Though (C and D) are likely indicated, these
actions do not have the priority of (B).)
An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. –
Correct Answer :D. Gently life the client when moving into a desired position.
(To avoid shearing forces when repositioning, the client should be lifted gently
across a surface (D). Reddened areas should NOT be massaged (A) since this
may increase the damage to already traumatized skin. To control pain and
muscle spasms, active range of motion (B) may be limited on the affected leg.
The position described in (C) is contraindicated for a client with a fractured left
hip.)
The UAPs working on a chronic neuro unit ask the nurse to help them determine
the safest way to transfer an elderly client w/ left-sided weakness from the bed
to the chair. What method describes the correct transfer procedure for this
client?
A. Place the chair at a right angle to the bed on the client's left side before
moving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
A+ TEST BANK 3
, HESI Critical Care RN Exit Exam
C. Have the client place the left foot next to the chair and pivot to the left
before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on
the right foot. –
Correct Answer :D. Move the chair parallel to the right side of the bed, and stand
the client on the right foot.
( (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of
transfer and include the use of poor body mechanics by the caregiver.)
An elderly resident of a long-term care facility is no longer able to perform self-
care and is becoming progressively weaker. The resident previously requested
that no resuscitative efforts be performed, and the family requests hospice care.
What action should the nurse implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. –
Correct Answer :D. Notify the HCP of the family's request.
(The nurse should first communicate with HCP (D). Hospice care is provided for
clients with a limited life expectancy which must be identified by the HCP. (A) is
not necessary at this time. Once the HCP provides the transfer to hospice care,
the nurse can collaborate with the hospice staff and HCP to determine (B and C)
should be implemented.)
A+ TEST BANK 4
HESI Critical Care RN Exit Exam 3 QUESTIONS
AND CORRECT ANSWERS (100% CORRECT
ANSWERS) WITH RATIONALES/
GUARANTEED PASS GRADED A+
An elderly client who requires frequent monitoring fell and fractured a hip.
Which nurse is at greatest risk for a malpractice judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing
notes.
B. The nurse assigned to care for the client who was at lunch at the time of the
fall.
C. The nurse who transferred the client to the chair when the fall occurred.
A+ TEST BANK 1
, HESI Critical Care RN Exit Exam
D. The charge nurse who completed rounds 30 minutes before the fall occurred.
–
Correct Answer :C. The nurse who transferred the client to the chair when the
fall occurred.
(The four elements of malpractice are: breach of duty owed, failure to adhere to
the recognized standard of care, direct causation of injury, and evidence of
actual injury. The hip fracture is the actual injury and the standard of care was
"frequent monitoring." (C) implies the duty was owed and the injury occurred
while the nurse was in charge of the client's care. There is no evidence of
negligence in (A, B, and D). )
The nurse observes an unlicensed assistive personnel (UAP) taking a client's
blood pressure with a cuff that is too small, but the blood pressure reading
obtained is within the client's usual range. What action is most important for the
nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. –
Correct Answer :B. Reassess the client's blood pressure using a larger cuff.
(The most important action is to ensure that an accurate BP reading is obtained.
The nurse should reassess the BP with the correct size cuff (B). Reassessment
A+ TEST BANK 2
, HESI Critical Care RN Exit Exam
should not be postponed (A). Though (C and D) are likely indicated, these
actions do not have the priority of (B).)
An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. –
Correct Answer :D. Gently life the client when moving into a desired position.
(To avoid shearing forces when repositioning, the client should be lifted gently
across a surface (D). Reddened areas should NOT be massaged (A) since this
may increase the damage to already traumatized skin. To control pain and
muscle spasms, active range of motion (B) may be limited on the affected leg.
The position described in (C) is contraindicated for a client with a fractured left
hip.)
The UAPs working on a chronic neuro unit ask the nurse to help them determine
the safest way to transfer an elderly client w/ left-sided weakness from the bed
to the chair. What method describes the correct transfer procedure for this
client?
A. Place the chair at a right angle to the bed on the client's left side before
moving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
A+ TEST BANK 3
, HESI Critical Care RN Exit Exam
C. Have the client place the left foot next to the chair and pivot to the left
before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on
the right foot. –
Correct Answer :D. Move the chair parallel to the right side of the bed, and stand
the client on the right foot.
( (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of
transfer and include the use of poor body mechanics by the caregiver.)
An elderly resident of a long-term care facility is no longer able to perform self-
care and is becoming progressively weaker. The resident previously requested
that no resuscitative efforts be performed, and the family requests hospice care.
What action should the nurse implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. Transfer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. –
Correct Answer :D. Notify the HCP of the family's request.
(The nurse should first communicate with HCP (D). Hospice care is provided for
clients with a limited life expectancy which must be identified by the HCP. (A) is
not necessary at this time. Once the HCP provides the transfer to hospice care,
the nurse can collaborate with the hospice staff and HCP to determine (B and C)
should be implemented.)
A+ TEST BANK 4
