HESI CRITICAL CARE EXIT EXAM 2023 SCREENSHOT / CRITICAL
CARE HESI EXIT EXAM 2023 ACTUAL EXAM
The nurses calculating fluid resuscitation for young adult male who was burned in a
bloody accident at 1200 and is seen in the ER at 1400. The HCP determines that the
client has burn over 30% of his body, mainly over his arms and chest. Using the
Parkland formula for fluid resuscitation, the client is to receive 7000 mL of fluid in 24
hours. Which goal should the nurse establish for this clients plan of care? - ANSWER:
By 2000, the client will have received 3500 mL of fluid
When caring for a client on a vent, which finding provides the greatest indication
that the client has an open airway? - ANSWER: Bilateral breath sounds can be
auscultated
The nurse performs a prescribed a neurological check at the beginning of the shift on
a client who was admitted with a subarachnoid brain attack (Stroke). The client's GCS
is 9. What information is most important for the nurse to determine? - ANSWER: The
client's previous GCS score
An adult female with a history of type 1 diabetes has been vomiting for the past 48
hours and is admitted to the ICU with DKA. Which assessment finding warrants
immediate intervention by the nurse? - ANSWER: Excessive thirst
A client admitted to the ICU after a colon resection with the formation of the loop
colostomy. The nurse determines that the clients abdominal dressing is clean and
dry. Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine output of 10
mL/hr. What interventions should the nurse implement? - ANSWER: Give a 500 mL
IV fluid bolus challenge
A client is admitted with syncopal episodes related to a third degree heart block.
After the placement of a transcutaneous pacemaker, the nurse observes several
episodes the pacemaker failure to sense. What action should the nurse take? -
ANSWER: Increase the sensitivity
A client is receiving CPR. After systole is confirmed in two leads and sending the
transcutaneous pacemaker, which IV medication should be administered? -
ANSWER: Epinephrine (adrenaline)
A client has a chest tube connected to a closed water seal drainage system with
suction. What equipment should the nurse always have available at the clients
bedside? - ANSWER: Occlusive dressing
Bretylium 1 mg/min via infusion is prescribed for a client and ventricular tachycardia.
The available solution is 500 mL D5W contains bretylium 1 gram. The nurse should
program the infusion time to deliver how many mL/hr? - ANSWER: 30
, The client is receiving an infusion of nitroglycerin 100 mg and 500 mL D5W at 6
mL/hr. How many mcg/min of nitroglycerin is infusing? - ANSWER: 20
A client arrives in the ER complaining of pain. What description of pain should
prompt the nurse to suspect it originated in the myocardium? - ANSWER: Produces
chest heaviness with left arm pain
Four days ago a chest tube was inserted into the second intercostal space of a client
who has a pneumothorax. Today the nurse notes that there is no fluctuation in the
water-seal chamber of the Pleuravac. Which intervention would be most appropriate
for the nurse to implement? - ANSWER: Assess the clients breath sounds of the
affected lung
In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize which intervention is essential? - ANSWER: Encourage the
client to breathe deeply and cough at frequent intervals
A postoperative client is admitted the ICU with an inflated pressure infuser
containing solution of heparin 2 units/mL attached to an intraarterial cannula. Which
finding indicated that the heparin infusion has achieved its therapeutic use? -
ANSWER: Intra-arterial cannula remain patent
The nurse suspects that a client with a central venous catheter in the left subclavian
vein is experiencing an embolism. What signs and symptoms are most indicative of
this condition? - ANSWER: Anxiety, confusion, lightheadedness, and loss
consciousness
A female client has been in systole for 20 minutes. She is intubated, and epinephrine
(adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in
rhythm. What intervention should the nurse implement? - ANSWER: Bring members
of the family to a private area to discuss the desire to continue life saving efforts
The nurse is evaluating a clients central venous pressure reading that are trending
upwards. What nursing diagnosis is supported but the pathophysiological
mechanism most likely causing this increase? - ANSWER: Impaired cardiac output
The high pressure alarm on a mechanical vent is alarming. What intervention should
the nurse implement immediately? - ANSWER: Auscultate bilaterally for breath
sounds and confirm endotracheal suctioning
A client with a history of vasovagal attacks resulting in brady-dysrhythmias. Which
instruction is the most important in the teaching plan? - ANSWER: Use stool
softeners regularly
CARE HESI EXIT EXAM 2023 ACTUAL EXAM
The nurses calculating fluid resuscitation for young adult male who was burned in a
bloody accident at 1200 and is seen in the ER at 1400. The HCP determines that the
client has burn over 30% of his body, mainly over his arms and chest. Using the
Parkland formula for fluid resuscitation, the client is to receive 7000 mL of fluid in 24
hours. Which goal should the nurse establish for this clients plan of care? - ANSWER:
By 2000, the client will have received 3500 mL of fluid
When caring for a client on a vent, which finding provides the greatest indication
that the client has an open airway? - ANSWER: Bilateral breath sounds can be
auscultated
The nurse performs a prescribed a neurological check at the beginning of the shift on
a client who was admitted with a subarachnoid brain attack (Stroke). The client's GCS
is 9. What information is most important for the nurse to determine? - ANSWER: The
client's previous GCS score
An adult female with a history of type 1 diabetes has been vomiting for the past 48
hours and is admitted to the ICU with DKA. Which assessment finding warrants
immediate intervention by the nurse? - ANSWER: Excessive thirst
A client admitted to the ICU after a colon resection with the formation of the loop
colostomy. The nurse determines that the clients abdominal dressing is clean and
dry. Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine output of 10
mL/hr. What interventions should the nurse implement? - ANSWER: Give a 500 mL
IV fluid bolus challenge
A client is admitted with syncopal episodes related to a third degree heart block.
After the placement of a transcutaneous pacemaker, the nurse observes several
episodes the pacemaker failure to sense. What action should the nurse take? -
ANSWER: Increase the sensitivity
A client is receiving CPR. After systole is confirmed in two leads and sending the
transcutaneous pacemaker, which IV medication should be administered? -
ANSWER: Epinephrine (adrenaline)
A client has a chest tube connected to a closed water seal drainage system with
suction. What equipment should the nurse always have available at the clients
bedside? - ANSWER: Occlusive dressing
Bretylium 1 mg/min via infusion is prescribed for a client and ventricular tachycardia.
The available solution is 500 mL D5W contains bretylium 1 gram. The nurse should
program the infusion time to deliver how many mL/hr? - ANSWER: 30
, The client is receiving an infusion of nitroglycerin 100 mg and 500 mL D5W at 6
mL/hr. How many mcg/min of nitroglycerin is infusing? - ANSWER: 20
A client arrives in the ER complaining of pain. What description of pain should
prompt the nurse to suspect it originated in the myocardium? - ANSWER: Produces
chest heaviness with left arm pain
Four days ago a chest tube was inserted into the second intercostal space of a client
who has a pneumothorax. Today the nurse notes that there is no fluctuation in the
water-seal chamber of the Pleuravac. Which intervention would be most appropriate
for the nurse to implement? - ANSWER: Assess the clients breath sounds of the
affected lung
In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize which intervention is essential? - ANSWER: Encourage the
client to breathe deeply and cough at frequent intervals
A postoperative client is admitted the ICU with an inflated pressure infuser
containing solution of heparin 2 units/mL attached to an intraarterial cannula. Which
finding indicated that the heparin infusion has achieved its therapeutic use? -
ANSWER: Intra-arterial cannula remain patent
The nurse suspects that a client with a central venous catheter in the left subclavian
vein is experiencing an embolism. What signs and symptoms are most indicative of
this condition? - ANSWER: Anxiety, confusion, lightheadedness, and loss
consciousness
A female client has been in systole for 20 minutes. She is intubated, and epinephrine
(adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in
rhythm. What intervention should the nurse implement? - ANSWER: Bring members
of the family to a private area to discuss the desire to continue life saving efforts
The nurse is evaluating a clients central venous pressure reading that are trending
upwards. What nursing diagnosis is supported but the pathophysiological
mechanism most likely causing this increase? - ANSWER: Impaired cardiac output
The high pressure alarm on a mechanical vent is alarming. What intervention should
the nurse implement immediately? - ANSWER: Auscultate bilaterally for breath
sounds and confirm endotracheal suctioning
A client with a history of vasovagal attacks resulting in brady-dysrhythmias. Which
instruction is the most important in the teaching plan? - ANSWER: Use stool
softeners regularly
