HESI Critical Care RN Exit Exam –
Real ICU-Level Questions with
Clinical Prioritization & Emergency
Scenarios with Rationales
1. A patient is admitted to the ICU with a diagnosis of septic shock.
The initial blood pressure is 74/48 mm Hg, heart rate is 122 bpm, and
central venous pressure (CVP) is 3 mm Hg. The healthcare provider
prescribes a fluid bolus of 30 mL/kg of isotonic crystalloid. Which
assessment finding is the most important indicator of a positive
response to this initial fluid resuscitation?
A. An increase in CVP to 5 mm Hg
B. A decrease in heart rate to 110 bpm
C. A urinary output of 0.8 mL/kg/hour
D. A mean arterial pressure (MAP) of 55 mm Hg
Answer: C
Rationale: The primary goal of initial fluid resuscitation in septic shock is to
improve tissue perfusion and organ function. While a single number is less
informative than a trend, a urinary output of 0.5-1 mL/kg/hour is a key
clinical marker of adequate renal perfusion and a positive response to
resuscitation, indicating that cardiac output and blood flow to the kidneys
have improved. An MAP > 65 mm Hg is a typical target, making option D
(55 mm Hg) inadequate. An increase in CVP (option A) indicates increased
preload but does not guarantee improved perfusion, and a decrease in
heart rate (option B) can be a non-specific finding that is not the most
definitive endpoint.
,2. A nurse is caring for a patient who is 6 hours post-cardiac
catheterization with a femoral artery access site. Upon assessment, the
nurse notes a large, expanding hematoma in the right groin and the
patient reports severe pain in the right lower extremity. The toes on
the right foot are pale and cool to touch, with a diminished posterior
tibial pulse. What is the nurse's priority action?
A. Apply firm, direct pressure 1-2 cm above the catheter insertion site.
B. Reassess the vital signs and peripheral pulses in 15 minutes.
C. Elevate the head of the bed to 45 degrees to promote comfort.
D. Administer the prescribed PRN opioid analgesic for the patient’s pain.
Answer: A
Rationale: This is a critical situation indicating a retroperitoneal hematoma
or pseudoaneurysm causing arterial compression. This is a life-threatening
complication. The priority action is to apply firm, direct pressure
proximal to the insertion site to attempt to control the bleeding and
restore arterial flow. Waiting 15 minutes (option B) or elevating the head of
the bed (option C) would delay life-saving intervention. While pain (option
D) is a concern, it is secondary to ischemic threat to the limb and the
potential for hemorrhagic shock.
3. The nurse is evaluating the telemetry rhythm of a patient in the
cardiac ICU. The rhythm strip shows a regular narrow QRS complex at
a rate of 160 beats per minute. P waves are not clearly visible. The
patient is awake and alert, with a blood pressure of 102/68 mm Hg,
and reports feeling "a little dizzy." Which PRN medication should the
nurse administer for this rhythm?
A. Amiodarone 150 mg IV push over 10 minutes.
B. Adenosine 6 mg rapid IV push.
C. Atropine 0.5 mg IV push.
D. Metoprolol 5 mg IV push over 2 minutes.
Answer: B
,Rationale: The described rhythm is consistent with supraventricular
tachycardia (SVT). In a hemodynamically stable patient (BP is stable,
though the patient is dizzy), the initial medication of choice for acute SVT
is adenosine. Adenosine works by temporarily blocking the AV node to
interrupt the re-entrant circuit. The initial dose is 6 mg given as a rapid IV
push followed by a rapid saline flush, with a second dose of 12 mg if
needed. Amiodarone (option A) is used for atrial fibrillation or ventricular
arrhythmias. Atropine (option C) is for symptomatic bradycardia.
Metoprolol (option D) is not the first-line agent for acute termination.
Respiratory Failure & Mechanical Ventilation
4. A patient is receiving mechanical ventilation in the ICU. Which
assessment finding is the most important indicator that the patient has
an open and patent airway?
A. The ventilator's peak inspiratory pressure is 25 cm H₂O.
B. The capnography waveform shows a normal shape and ETCO₂ of 38 mm
Hg.
C. Bilateral breath sounds are auscultated in the posterior bases.
D. Symmetrical chest rise is observed with each ventilator breath.
Answer: B
Rationale: While options C and D provide data about ventilation
distribution, capnography is the gold standard for immediate confirmation
of endotracheal tube patency and placement. A normal capnography
waveform and a physiologic ETCO₂ (35-45 mm Hg) confirm that exhaled
carbon dioxide is being detected, which indicates the tube is in the airway
and patent. A patient can have bilateral breath sounds (option C) and
symmetrical chest rise (option D) with accidental esophageal intubation or
mainstem intubation underneath breath sounds transmission muscle
movement.
5. The ICU nurse is assessing a patient who is intubated and on a
mechanical ventilator. The high-pressure alarm is sounding. After a
, quick assessment, the nurse notes that the patient has absent breath
sounds on the left side, and the trachea is deviated to the right. What
is the nurse's priority action?
A. Reposition the patient to the left side-lying position.
B. Prepare for emergency needle decompression.
C. Suction the endotracheal tube for a mucus plug.
D. Hyper-oxygenate the patient and have them cough.
Answer: B
Rationale: This patient is presenting with a tension pneumothorax. The
signs include absent breath sounds unilaterally, tracheal deviation (a late
sign), and high-pressure alarms. This is a life-threatening emergency. The
priority action is to prepare for immediate needle decompression with a
large-bore IV catheter in the second intercostal space, midclavicular line, to
release the trapped air and relieve pressure on the heart and great vessels.
Repositioning (option A) or suctioning (option C) will not resolve the
tension pneumothorax.
Neurological Emergencies
6. A patient with a traumatic brain injury (TBI) is being monitored for
increased intracranial pressure (ICP). Which clinical finding is the
earliest and most sensitive indicator of a change in cerebral function?
A. Change in the level of consciousness.
B. Development of a fixed and dilated pupil.
C. Widening pulse pressure.
D. Decerebrate posturing.
Answer: A
Rationale: A change in the level of consciousness (LOC), as measured by
responses to commands on the Glasgow Coma Scale, is the first and most
sensitive sign of altered cerebral function in the patient with a TBI. Focal
neurological signs, such as unequal pupils (option B), occur later as ICP
increases and causes herniation. Cushing's triad (widening pulse pressure,
Real ICU-Level Questions with
Clinical Prioritization & Emergency
Scenarios with Rationales
1. A patient is admitted to the ICU with a diagnosis of septic shock.
The initial blood pressure is 74/48 mm Hg, heart rate is 122 bpm, and
central venous pressure (CVP) is 3 mm Hg. The healthcare provider
prescribes a fluid bolus of 30 mL/kg of isotonic crystalloid. Which
assessment finding is the most important indicator of a positive
response to this initial fluid resuscitation?
A. An increase in CVP to 5 mm Hg
B. A decrease in heart rate to 110 bpm
C. A urinary output of 0.8 mL/kg/hour
D. A mean arterial pressure (MAP) of 55 mm Hg
Answer: C
Rationale: The primary goal of initial fluid resuscitation in septic shock is to
improve tissue perfusion and organ function. While a single number is less
informative than a trend, a urinary output of 0.5-1 mL/kg/hour is a key
clinical marker of adequate renal perfusion and a positive response to
resuscitation, indicating that cardiac output and blood flow to the kidneys
have improved. An MAP > 65 mm Hg is a typical target, making option D
(55 mm Hg) inadequate. An increase in CVP (option A) indicates increased
preload but does not guarantee improved perfusion, and a decrease in
heart rate (option B) can be a non-specific finding that is not the most
definitive endpoint.
,2. A nurse is caring for a patient who is 6 hours post-cardiac
catheterization with a femoral artery access site. Upon assessment, the
nurse notes a large, expanding hematoma in the right groin and the
patient reports severe pain in the right lower extremity. The toes on
the right foot are pale and cool to touch, with a diminished posterior
tibial pulse. What is the nurse's priority action?
A. Apply firm, direct pressure 1-2 cm above the catheter insertion site.
B. Reassess the vital signs and peripheral pulses in 15 minutes.
C. Elevate the head of the bed to 45 degrees to promote comfort.
D. Administer the prescribed PRN opioid analgesic for the patient’s pain.
Answer: A
Rationale: This is a critical situation indicating a retroperitoneal hematoma
or pseudoaneurysm causing arterial compression. This is a life-threatening
complication. The priority action is to apply firm, direct pressure
proximal to the insertion site to attempt to control the bleeding and
restore arterial flow. Waiting 15 minutes (option B) or elevating the head of
the bed (option C) would delay life-saving intervention. While pain (option
D) is a concern, it is secondary to ischemic threat to the limb and the
potential for hemorrhagic shock.
3. The nurse is evaluating the telemetry rhythm of a patient in the
cardiac ICU. The rhythm strip shows a regular narrow QRS complex at
a rate of 160 beats per minute. P waves are not clearly visible. The
patient is awake and alert, with a blood pressure of 102/68 mm Hg,
and reports feeling "a little dizzy." Which PRN medication should the
nurse administer for this rhythm?
A. Amiodarone 150 mg IV push over 10 minutes.
B. Adenosine 6 mg rapid IV push.
C. Atropine 0.5 mg IV push.
D. Metoprolol 5 mg IV push over 2 minutes.
Answer: B
,Rationale: The described rhythm is consistent with supraventricular
tachycardia (SVT). In a hemodynamically stable patient (BP is stable,
though the patient is dizzy), the initial medication of choice for acute SVT
is adenosine. Adenosine works by temporarily blocking the AV node to
interrupt the re-entrant circuit. The initial dose is 6 mg given as a rapid IV
push followed by a rapid saline flush, with a second dose of 12 mg if
needed. Amiodarone (option A) is used for atrial fibrillation or ventricular
arrhythmias. Atropine (option C) is for symptomatic bradycardia.
Metoprolol (option D) is not the first-line agent for acute termination.
Respiratory Failure & Mechanical Ventilation
4. A patient is receiving mechanical ventilation in the ICU. Which
assessment finding is the most important indicator that the patient has
an open and patent airway?
A. The ventilator's peak inspiratory pressure is 25 cm H₂O.
B. The capnography waveform shows a normal shape and ETCO₂ of 38 mm
Hg.
C. Bilateral breath sounds are auscultated in the posterior bases.
D. Symmetrical chest rise is observed with each ventilator breath.
Answer: B
Rationale: While options C and D provide data about ventilation
distribution, capnography is the gold standard for immediate confirmation
of endotracheal tube patency and placement. A normal capnography
waveform and a physiologic ETCO₂ (35-45 mm Hg) confirm that exhaled
carbon dioxide is being detected, which indicates the tube is in the airway
and patent. A patient can have bilateral breath sounds (option C) and
symmetrical chest rise (option D) with accidental esophageal intubation or
mainstem intubation underneath breath sounds transmission muscle
movement.
5. The ICU nurse is assessing a patient who is intubated and on a
mechanical ventilator. The high-pressure alarm is sounding. After a
, quick assessment, the nurse notes that the patient has absent breath
sounds on the left side, and the trachea is deviated to the right. What
is the nurse's priority action?
A. Reposition the patient to the left side-lying position.
B. Prepare for emergency needle decompression.
C. Suction the endotracheal tube for a mucus plug.
D. Hyper-oxygenate the patient and have them cough.
Answer: B
Rationale: This patient is presenting with a tension pneumothorax. The
signs include absent breath sounds unilaterally, tracheal deviation (a late
sign), and high-pressure alarms. This is a life-threatening emergency. The
priority action is to prepare for immediate needle decompression with a
large-bore IV catheter in the second intercostal space, midclavicular line, to
release the trapped air and relieve pressure on the heart and great vessels.
Repositioning (option A) or suctioning (option C) will not resolve the
tension pneumothorax.
Neurological Emergencies
6. A patient with a traumatic brain injury (TBI) is being monitored for
increased intracranial pressure (ICP). Which clinical finding is the
earliest and most sensitive indicator of a change in cerebral function?
A. Change in the level of consciousness.
B. Development of a fixed and dilated pupil.
C. Widening pulse pressure.
D. Decerebrate posturing.
Answer: A
Rationale: A change in the level of consciousness (LOC), as measured by
responses to commands on the Glasgow Coma Scale, is the first and most
sensitive sign of altered cerebral function in the patient with a TBI. Focal
neurological signs, such as unequal pupils (option B), occur later as ICP
increases and causes herniation. Cushing's triad (widening pulse pressure,
