Critical Care Exit HESI QUESTIONS AND ANSWERS
2022
A nurse who is working in the emergency department triage area is presented with
four clients at the same time. The client presented with which symptoms requires the
most immediate intervention by the nurse?
● Low-grade fever, headache, and malaise for the past 72 hours
● Unable to bear weight on the left foot, with the swelling and bruising
● Chest discomfort one hour after consuming a large, spicy meal
● One-inch bleeding laceration on the chain of the crying five-year-old Correct Answer: ● Chest
discomfort one hour after consuming a large, spicy meal
Rationale: Emergency triage involves quick assessment to prioritize the need for
further evaluation and care. Those with trauma, chest pain, respiratory distress, or
acute neurological changes are priority. In this example, while clients with other
conditions require attention, the client with chest discomfort is at greatest risk and
is a priority.
The nurse is planning to assess a client's oxygen saturation to determine if
additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee
amputation and pedal pulses that are weak and threaty. What action should the nurse
take?
● Document that an accurate oxygen saturation reading cannot be obtained
● Elevate to client's hands for five minutes prior to obtaining a reading from the
finger
● Increase the oxygen based on the clients breathing patterns and lung sounds
● Place the oximeter clip on the ear lobe to obtain the oxygen saturation
reading Correct Answer: ● Place the oximeter clip on the ear lobe to obtain the oxygen
saturation reading
Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an
accurate measurement of oxygen saturation. Other options will not provide the
needed assessment.
A male client reports to the clinic nurse that he has been feeling well and is often
"dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest
risk for which pathophysiological condition?
● Stroke
● Renal failure
● Left ventricular hypertrophy
● Pulmonary hypertension Correct Answer: ● Stroke
The nurse is changing a client's IV tubing and closes the roller clamp on the new
tubing setup when the bag of solution is....which action should the nurse take to ensure
,adequate filling of the drip chamber?
● Lower the IV bag to a flat surface
● Compress the drip chamber
● Open the roller clamp
● Squeeze the bag of IV solution Correct Answer: ● Compress the drip chamber
...An Insulin infusion for a client with diabetes mellitus who is experiencing
hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value
is most important for the nurse to monitor?
● Serum potassium
● Urine ketones
● Urine albumin
● Serum protein Correct Answer: ● Serum potassium
A young adult who is hit with a baseball bat on the temporal area of the left skull
is conscious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
● Altered consciousness within the first 24 hours after injury.
● Cushing reflex and cerebral edema after 24 hours
● Fever, nuchal rigidity and opisthotonos within hours
● Headache and pupillary changes 48 hours after a head injury Correct Answer: ● Altered
consciousness within the first 24 hours after injury.
A client with a serum sodium level of 125 meq/mL should benefit most from the
administration of which intravenous solution?
● 0.9% sodium chloride solution (normal saline)
● 0.45% sodium chloride solution (half normal saline)
● 10% Dextrose in 0.45% sodium chloride
● 5% dextrose in 0.2% sodium chloride Correct Answer: ● 0.9% sodium chloride solution
(normal saline)
After placement of a left subclavian central venous catheter (CVC), the nurse receives
report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which
action should the nurse implement?
● Initiate intravenous fluid as prescribed
● Notify the HCP of the need to reposition the catheter
● Remove the catheter and apply direct pressure for 5 minute
● Secure the catheter using aseptic technique Correct Answer: ● Initiate intravenous fluid as
prescribed
Rationale: Venous blood return to the heart and drains from the subclavian vein into the
superior vena cava. The X-ray findings indicate proper placement of the CVC, so
prescribed intravenous fluid can be started. A and B are not indicated at this time. The
catheter should be secure immediate following insertion (C)
, The nurse has received funding to design a health promotion project for African-
American women who are at risk for developing breast cancer. Which resource is most
important in designing this program?
● A listing of African-American women so live in the community
● Participation of community leaders in planning the program
● Morbidity data for breast cancer in women of all races
● Technical assistance to produce a video on breast self-examination. Correct Answer: ●
Participation of community leaders in planning the program
The home care nurse provide self-care instruction for a client chronic venous
insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the
client's discharge teaching plan? Select all that apply
● Avoid prolonged standing or sitting
● Use recliner for long period of sitting
● continue wearing elastic stocking
● Maintain the bed flat while sleeping
● Cross legs at knee but not at ankle Correct Answer: ● Avoid prolonged standing or sitting
● Use recliner for long period of sitting
● continue wearing elastic stocking
A male client was transferred yesterday from the emergency department to the
telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor
alarms for ventricular tachycardia (VT), what action should the nurse take first?
● Determine the client's responsiveness and respirations
● Bring the crash cart to the room to defibrillate the client.
● Immediately initiate chest compressions.
● Notify the emergency response team Correct Answer: ● Determine the client's responsiveness
and respirations
A client with a large pleural effusion undergoes a thoracentesis. Following the
procedure, which assessment finding warrants immediate intervention by the nurse?
● The client has asymmetrical chest wall expansion
● The clients complain of pain at the insertion site
● The client chest's x-ray indicates decreased pleural effusion
● The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26 Correct Answer:
● The client has asymmetrical chest wall expansion
A potential complication of thoracentesis is a pneumothorax. The symptoms
of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected
finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis
and C is within normal limits.
The nurse is preparing a client for discharge from the hospital following a liver
transplant. Which instruction is most important for the nurse to include in this client's discharge
teaching plan?
2022
A nurse who is working in the emergency department triage area is presented with
four clients at the same time. The client presented with which symptoms requires the
most immediate intervention by the nurse?
● Low-grade fever, headache, and malaise for the past 72 hours
● Unable to bear weight on the left foot, with the swelling and bruising
● Chest discomfort one hour after consuming a large, spicy meal
● One-inch bleeding laceration on the chain of the crying five-year-old Correct Answer: ● Chest
discomfort one hour after consuming a large, spicy meal
Rationale: Emergency triage involves quick assessment to prioritize the need for
further evaluation and care. Those with trauma, chest pain, respiratory distress, or
acute neurological changes are priority. In this example, while clients with other
conditions require attention, the client with chest discomfort is at greatest risk and
is a priority.
The nurse is planning to assess a client's oxygen saturation to determine if
additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee
amputation and pedal pulses that are weak and threaty. What action should the nurse
take?
● Document that an accurate oxygen saturation reading cannot be obtained
● Elevate to client's hands for five minutes prior to obtaining a reading from the
finger
● Increase the oxygen based on the clients breathing patterns and lung sounds
● Place the oximeter clip on the ear lobe to obtain the oxygen saturation
reading Correct Answer: ● Place the oximeter clip on the ear lobe to obtain the oxygen
saturation reading
Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an
accurate measurement of oxygen saturation. Other options will not provide the
needed assessment.
A male client reports to the clinic nurse that he has been feeling well and is often
"dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest
risk for which pathophysiological condition?
● Stroke
● Renal failure
● Left ventricular hypertrophy
● Pulmonary hypertension Correct Answer: ● Stroke
The nurse is changing a client's IV tubing and closes the roller clamp on the new
tubing setup when the bag of solution is....which action should the nurse take to ensure
,adequate filling of the drip chamber?
● Lower the IV bag to a flat surface
● Compress the drip chamber
● Open the roller clamp
● Squeeze the bag of IV solution Correct Answer: ● Compress the drip chamber
...An Insulin infusion for a client with diabetes mellitus who is experiencing
hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value
is most important for the nurse to monitor?
● Serum potassium
● Urine ketones
● Urine albumin
● Serum protein Correct Answer: ● Serum potassium
A young adult who is hit with a baseball bat on the temporal area of the left skull
is conscious when admitted to the ED and is transferred to the Neurological Unit to be
monitored for signs of closed head injury. Which assessment finding is indicative of a
developing epidural hematoma?
● Altered consciousness within the first 24 hours after injury.
● Cushing reflex and cerebral edema after 24 hours
● Fever, nuchal rigidity and opisthotonos within hours
● Headache and pupillary changes 48 hours after a head injury Correct Answer: ● Altered
consciousness within the first 24 hours after injury.
A client with a serum sodium level of 125 meq/mL should benefit most from the
administration of which intravenous solution?
● 0.9% sodium chloride solution (normal saline)
● 0.45% sodium chloride solution (half normal saline)
● 10% Dextrose in 0.45% sodium chloride
● 5% dextrose in 0.2% sodium chloride Correct Answer: ● 0.9% sodium chloride solution
(normal saline)
After placement of a left subclavian central venous catheter (CVC), the nurse receives
report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which
action should the nurse implement?
● Initiate intravenous fluid as prescribed
● Notify the HCP of the need to reposition the catheter
● Remove the catheter and apply direct pressure for 5 minute
● Secure the catheter using aseptic technique Correct Answer: ● Initiate intravenous fluid as
prescribed
Rationale: Venous blood return to the heart and drains from the subclavian vein into the
superior vena cava. The X-ray findings indicate proper placement of the CVC, so
prescribed intravenous fluid can be started. A and B are not indicated at this time. The
catheter should be secure immediate following insertion (C)
, The nurse has received funding to design a health promotion project for African-
American women who are at risk for developing breast cancer. Which resource is most
important in designing this program?
● A listing of African-American women so live in the community
● Participation of community leaders in planning the program
● Morbidity data for breast cancer in women of all races
● Technical assistance to produce a video on breast self-examination. Correct Answer: ●
Participation of community leaders in planning the program
The home care nurse provide self-care instruction for a client chronic venous
insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the
client's discharge teaching plan? Select all that apply
● Avoid prolonged standing or sitting
● Use recliner for long period of sitting
● continue wearing elastic stocking
● Maintain the bed flat while sleeping
● Cross legs at knee but not at ankle Correct Answer: ● Avoid prolonged standing or sitting
● Use recliner for long period of sitting
● continue wearing elastic stocking
A male client was transferred yesterday from the emergency department to the
telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor
alarms for ventricular tachycardia (VT), what action should the nurse take first?
● Determine the client's responsiveness and respirations
● Bring the crash cart to the room to defibrillate the client.
● Immediately initiate chest compressions.
● Notify the emergency response team Correct Answer: ● Determine the client's responsiveness
and respirations
A client with a large pleural effusion undergoes a thoracentesis. Following the
procedure, which assessment finding warrants immediate intervention by the nurse?
● The client has asymmetrical chest wall expansion
● The clients complain of pain at the insertion site
● The client chest's x-ray indicates decreased pleural effusion
● The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26 Correct Answer:
● The client has asymmetrical chest wall expansion
A potential complication of thoracentesis is a pneumothorax. The symptoms
of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected
finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis
and C is within normal limits.
The nurse is preparing a client for discharge from the hospital following a liver
transplant. Which instruction is most important for the nurse to include in this client's discharge
teaching plan?
