HESI RN CRITICAL CARE V2 (ACTUAL 2024 EXAM)
QUESTIONS AND CORRECT DETAILED ANSWERS
AGRADE
RATED
The triage nurse is assessing a victim of a stab wound. According to the paramedics,
the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length
and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two inches above
and left of the victim's xiphoid process. Which vital organ(s) are at an increased risk of
being in the direct path of injury? - ANSWER✔✔Heart
Lungs
Diaphragm
A client reports to the nurse feeling achy and weak, being tired and coughing all the
time, frequent headaches and experiencing night sweats. The client's assessment is
significant for crackles scattered throughout the lungs, dependent peripheral edema
+3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110
beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg
with a mean arterial pressure of (75). Which diagnostic procedure should the nurse
prepare to do first? - ANSWER✔✔Blood culture
According to the paramedic's report, the victim of a motor vehicle collision was sitting in
the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic
light when the vehicle was hit on the left side by another vehicle traveling at speeds
,exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L)
side of thorax and body. The significant assessment findings include: weak and thready
pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is
diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is
present in the (L) flank area and progresses towards the abdomen. Vital signs are
temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22
breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2
lpm O2 via nasal cannula. - ANSWER✔✔Fractured liver & ruptured spleen
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly
ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How
should the nurse interpret this blood gas? - ANSWER✔✔Respiratory alkalosis
A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is
admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L.
Which protocol prescription should the nurse implement first? - ANSWER✔✔Obtain
serum sodium every 4 hours
The nurse is caring for a client who is demonstrating signs of impending death. The
family is experiencing emotional distress as the client's condition declines. Which
information should the nurse provide the family to facilitate the process? - ANSWER✔
✔Encourage the family to give the patient permission to die
The nurse is caring for a client with severe sepsis related to a ruptured appendix.The
clientis diaphoretic and reports lower extremity spasms. The nurse observes
respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60,
PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding
warrants immediate intervention by the nurse? - ANSWER✔✔Intercostal muscle
contraction
What way do females stab? - ANSWER✔✔Downwards
What way do males stab? - ANSWER✔✔Upwards
, Define: Infective endocarditis - ANSWER✔✔Infection of the endocardial surface of the
heart, usually the heart valves
What indicates ineffective endocarditis? - ANSWER✔✔Edema & S1/S3 sounds
Define: Respiratory alkalosis - ANSWER✔✔HCO3 & pH is increased while the CO2 is
decreased
What is the effect if blood sugar continues to rise? - ANSWER✔✔Change in level of
consciousness
What precaution should a patient be on with a high sodium? - ANSWER✔✔Seizure
precautions
Why do people with diabetes have an increased urinary output? - ANSWER✔✔Low
ADH
What is the effect of a low ADH? - ANSWER✔✔Dehydration & increased serum
Sodium
Define: Intercostal muscle contraction - ANSWER✔✔Critical sign of respiratory muscle
fatigue which is likely to lead to acute respiratory failure
Define: Cistacurium - ANSWER✔✔Paralytic during surgery
A client who experienced an intracranial hemorrhage is receiving cistracurium to induce
a pharmacological state of paralysis. Which intervention should the nurse implement
during the therapeutic paralysis? - ANSWER✔✔Administer a sedating medication
A client returns to the intensive care unit (ICU) after having a permanent pacemaker
inserted. Which finding should the nurse observe for during the immediate hours after
insertion? - ANSWER✔✔Beck's Triad
QUESTIONS AND CORRECT DETAILED ANSWERS
AGRADE
RATED
The triage nurse is assessing a victim of a stab wound. According to the paramedics,
the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length
and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two inches above
and left of the victim's xiphoid process. Which vital organ(s) are at an increased risk of
being in the direct path of injury? - ANSWER✔✔Heart
Lungs
Diaphragm
A client reports to the nurse feeling achy and weak, being tired and coughing all the
time, frequent headaches and experiencing night sweats. The client's assessment is
significant for crackles scattered throughout the lungs, dependent peripheral edema
+3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110
beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg
with a mean arterial pressure of (75). Which diagnostic procedure should the nurse
prepare to do first? - ANSWER✔✔Blood culture
According to the paramedic's report, the victim of a motor vehicle collision was sitting in
the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic
light when the vehicle was hit on the left side by another vehicle traveling at speeds
,exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L)
side of thorax and body. The significant assessment findings include: weak and thready
pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is
diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is
present in the (L) flank area and progresses towards the abdomen. Vital signs are
temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22
breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2
lpm O2 via nasal cannula. - ANSWER✔✔Fractured liver & ruptured spleen
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly
ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How
should the nurse interpret this blood gas? - ANSWER✔✔Respiratory alkalosis
A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is
admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L.
Which protocol prescription should the nurse implement first? - ANSWER✔✔Obtain
serum sodium every 4 hours
The nurse is caring for a client who is demonstrating signs of impending death. The
family is experiencing emotional distress as the client's condition declines. Which
information should the nurse provide the family to facilitate the process? - ANSWER✔
✔Encourage the family to give the patient permission to die
The nurse is caring for a client with severe sepsis related to a ruptured appendix.The
clientis diaphoretic and reports lower extremity spasms. The nurse observes
respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60,
PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding
warrants immediate intervention by the nurse? - ANSWER✔✔Intercostal muscle
contraction
What way do females stab? - ANSWER✔✔Downwards
What way do males stab? - ANSWER✔✔Upwards
, Define: Infective endocarditis - ANSWER✔✔Infection of the endocardial surface of the
heart, usually the heart valves
What indicates ineffective endocarditis? - ANSWER✔✔Edema & S1/S3 sounds
Define: Respiratory alkalosis - ANSWER✔✔HCO3 & pH is increased while the CO2 is
decreased
What is the effect if blood sugar continues to rise? - ANSWER✔✔Change in level of
consciousness
What precaution should a patient be on with a high sodium? - ANSWER✔✔Seizure
precautions
Why do people with diabetes have an increased urinary output? - ANSWER✔✔Low
ADH
What is the effect of a low ADH? - ANSWER✔✔Dehydration & increased serum
Sodium
Define: Intercostal muscle contraction - ANSWER✔✔Critical sign of respiratory muscle
fatigue which is likely to lead to acute respiratory failure
Define: Cistacurium - ANSWER✔✔Paralytic during surgery
A client who experienced an intracranial hemorrhage is receiving cistracurium to induce
a pharmacological state of paralysis. Which intervention should the nurse implement
during the therapeutic paralysis? - ANSWER✔✔Administer a sedating medication
A client returns to the intensive care unit (ICU) after having a permanent pacemaker
inserted. Which finding should the nurse observe for during the immediate hours after
insertion? - ANSWER✔✔Beck's Triad
