CRITICAL CARE HESI PRACTICE QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
GRADED A+ LATEST UPDATE 2024/2025
The nurse is caring for a client who presents with stroke-like symptoms. The
healthcare provider reviews the client's computerized axial tomography (CAT)
scan and prescribes recombinant tissue plasminogen activator (rtPA) IV. Which
information should the nurse obtain to determine if the client is a candidate for
this treatment now?
A.) Identify the underlying cause of this condition.
B.) Prepare to administer desmopressin (DDAVP).
C.) Decrease the intravenous fluids to a maintenance rate.
D.) Replace fluid losses with D5W every shift
B.) Prepare to administer desmopressin (DDAVP).
Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma to
the brain such as tumors or injury to the brain in particular the pituitary or hypothalamus
area. DI can also occur with cerebral edema present. The antidiuretic hormone
deficiency occurs rapidly and results in polyuria, anywhere between 5- 40 liters of
urine/24 hours. The client demonstrates signs and symptoms of hypovolemia.
Electrolyte imbalances include hypernatremia, along with hypokalemia and
hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are primarily
controlled through administration of exogenous ADH preparations, of which
desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored and
fluids are replaced every hour.
An intubated client is in the process of being weaned off ventilator support. The
client's baseline parameters are temperature 98.2 F (36.8 C), heart rate 88
beats/minute, respirations 14 breaths/minute, blood pressure 112/78 mmHg, and
,oxygen saturation 94%. Which assessment findings would indicate to the nurse
that the client is tolerating the weaning procedure? (Select all that apply.)
A.) Oxygen saturation is 91%
B.) Slight nasal flaring is present.
C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
E.) Respiratory rate is 36 breaths/minute.
A.) Oxygen saturation is 91%
C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
Criteria that indicates a client is tolerating weaning off ventilator support are respirations
greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen saturation
above 90%; heart rate that does not increase more than 20% from baseline heart rate;
most of the work of breathing is performed by the client; and no signs of accessory
muscles are used for breathing.
The nurse is assessing a burn victim who suffered destruction of the epidermis
and some of the dermis of the entire right arm and half the length of the right leg.
How should the nurse document the burn assessment findings?
A.) Superficial, 18% TBSA.
B.) Superficial partial-thickness, 18% TBSA.
C.) Deep-partial thickness, 27% TBSA.
D.) Full-thickness, 27% TBSA.
B.) Superficial partial-thickness, 18% TBSA
A "superficial partial-thickness" burn involves destruction of the epidermis layer and
some of the dermis layer. The total body surface area (%TBSA) is easily calculated by
using the "rule of nines" method. In this case, involvement of one arm is calculated as
9% TBSA and one-half of a leg is 9% TBSA for a combined total of 18% TBSA. A total
leg involvement is calculated as 18% TBSA.
he critical care nurse is providing care for a client diagnosed clinically brain dead
and identified as an organ donor. Which are the nurse's priorities in providing
, care? (Select all that apply.)
A.) Sustaining a state of hypothermia.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
Once an identified organ donor has been declared clinically brain dead, the primary
focus of care changes from preserving life to preserving organ functioning. This is done
by maintaining normal blood pressures, fluid levels, electrolytes levels, serum glucose
levels, and normothermia. Mechanical ventilation is provided to maintain adequate
oxygenation and normal acid-base balance. If needed, pharmaceutical support is
provided for the treatment of anemia, coagulopathy, thrombocytopenia, and diabetes
insipidus. Physiological changes occur to bodily functions as the result of decreased
perfusion within the brain.
A client is admitted to the intensive care unit with hematemesis related to
esophageal varices. Which assessment finding should the nurse identify that is
the result of an estimated blood loss at 35% of total blood volume?
A.) Absent bowel sounds.
B.) Coma.
C.) Anuria.
D.) Abdominal pain.
A.) Absent bowel sounds.
Massive blood loss redirects a significant amount of blood flow to vital organs. A client
who has lost 30% to 40% of the total blood volume will exhibit absent bowel sounds,
lethargy, and increased serum potassium.
ANSWERS WITH COMPLETE SOLUTIONS VERIFIED
GRADED A+ LATEST UPDATE 2024/2025
The nurse is caring for a client who presents with stroke-like symptoms. The
healthcare provider reviews the client's computerized axial tomography (CAT)
scan and prescribes recombinant tissue plasminogen activator (rtPA) IV. Which
information should the nurse obtain to determine if the client is a candidate for
this treatment now?
A.) Identify the underlying cause of this condition.
B.) Prepare to administer desmopressin (DDAVP).
C.) Decrease the intravenous fluids to a maintenance rate.
D.) Replace fluid losses with D5W every shift
B.) Prepare to administer desmopressin (DDAVP).
Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma to
the brain such as tumors or injury to the brain in particular the pituitary or hypothalamus
area. DI can also occur with cerebral edema present. The antidiuretic hormone
deficiency occurs rapidly and results in polyuria, anywhere between 5- 40 liters of
urine/24 hours. The client demonstrates signs and symptoms of hypovolemia.
Electrolyte imbalances include hypernatremia, along with hypokalemia and
hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are primarily
controlled through administration of exogenous ADH preparations, of which
desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored and
fluids are replaced every hour.
An intubated client is in the process of being weaned off ventilator support. The
client's baseline parameters are temperature 98.2 F (36.8 C), heart rate 88
beats/minute, respirations 14 breaths/minute, blood pressure 112/78 mmHg, and
,oxygen saturation 94%. Which assessment findings would indicate to the nurse
that the client is tolerating the weaning procedure? (Select all that apply.)
A.) Oxygen saturation is 91%
B.) Slight nasal flaring is present.
C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
E.) Respiratory rate is 36 breaths/minute.
A.) Oxygen saturation is 91%
C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
Criteria that indicates a client is tolerating weaning off ventilator support are respirations
greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen saturation
above 90%; heart rate that does not increase more than 20% from baseline heart rate;
most of the work of breathing is performed by the client; and no signs of accessory
muscles are used for breathing.
The nurse is assessing a burn victim who suffered destruction of the epidermis
and some of the dermis of the entire right arm and half the length of the right leg.
How should the nurse document the burn assessment findings?
A.) Superficial, 18% TBSA.
B.) Superficial partial-thickness, 18% TBSA.
C.) Deep-partial thickness, 27% TBSA.
D.) Full-thickness, 27% TBSA.
B.) Superficial partial-thickness, 18% TBSA
A "superficial partial-thickness" burn involves destruction of the epidermis layer and
some of the dermis layer. The total body surface area (%TBSA) is easily calculated by
using the "rule of nines" method. In this case, involvement of one arm is calculated as
9% TBSA and one-half of a leg is 9% TBSA for a combined total of 18% TBSA. A total
leg involvement is calculated as 18% TBSA.
he critical care nurse is providing care for a client diagnosed clinically brain dead
and identified as an organ donor. Which are the nurse's priorities in providing
, care? (Select all that apply.)
A.) Sustaining a state of hypothermia.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
Once an identified organ donor has been declared clinically brain dead, the primary
focus of care changes from preserving life to preserving organ functioning. This is done
by maintaining normal blood pressures, fluid levels, electrolytes levels, serum glucose
levels, and normothermia. Mechanical ventilation is provided to maintain adequate
oxygenation and normal acid-base balance. If needed, pharmaceutical support is
provided for the treatment of anemia, coagulopathy, thrombocytopenia, and diabetes
insipidus. Physiological changes occur to bodily functions as the result of decreased
perfusion within the brain.
A client is admitted to the intensive care unit with hematemesis related to
esophageal varices. Which assessment finding should the nurse identify that is
the result of an estimated blood loss at 35% of total blood volume?
A.) Absent bowel sounds.
B.) Coma.
C.) Anuria.
D.) Abdominal pain.
A.) Absent bowel sounds.
Massive blood loss redirects a significant amount of blood flow to vital organs. A client
who has lost 30% to 40% of the total blood volume will exhibit absent bowel sounds,
lethargy, and increased serum potassium.
