HESI CRITICAL CARE EXIT EXAM 2023 SCREENSHOT / CRITICAL
CARE HESI EXIT EXAM 2023 ACTUAL EXAM
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which
nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary radiation.
B. A nurse with Marfan's syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium difficile. - ANSWER:
B. A nurse with Marfan's syndrome who is postmenopausal.
RATIONALE:
A client receiving intracavity radiation poses a radiation hazard as long as the
intracavity
radiation source is in place. A nurse's ability to care of this client is not affected by
Marfan's
syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles,
ligaments
and skeletal structures. The goal is to limit any one staff member's exposure to the
calculated
time span based on the half-life of radium, such as the number of minutes at the
bedside per day,
so (A) should not be assigned. (C) should not be exposed to the radiation due to the
possible
effect on the fetus. A radiation exposure decreases the immune response in the
client who should
not be exposed to the potential inadvertent transmission of an infectious organism
(D).
1.A client who has active tuberculosis (TB) is admitted to the medical unit. What
action is most
important for the nurse to implement?
A. Fit the client with a respirator mask.
B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway - ANSWER: Assign the client to a negative air-
flow room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client
should be
assigned to a negative pressure air-flow room (D). Although (A and C) should be
implemented
for clients in isolation with contact precautions, it is most important that air flow
from the room
,is minimized when the client has TB. (B) should be implemented when the client
leaves the
isolation environment.
2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction.
The nurse
determines the client's apical pulse is 65 beats per minute. What action should the
nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. - ANSWER: Administer the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce
the heart rate,
so the medication should be administered (C) because the client's apical pulse is
greater than 60.
(A, B, and D) are not indicated at this time.
3.The nurse is assessing a client and identifies a bruit over the thyroid. This finding is
consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism - ANSWER: Hyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred
to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in glandular vascularity
which
increases as the thyroid gland becomes hyperactive. A bruit is not common with (A,
B, and C).
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a
basilar skull fracture. What
assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ANSWER: Rhinorrhoea or
otorrhoea with Halo sign.
RATIONALE:
,Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear
over the
mastoid process) are both signs of a basilar skull fracture, so the nurse should assess
for possible
meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose
(D). (A) is
consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder
or arm
fractures. (C) occurs with blunt abdominal injuries.
The nurse is assessing a client who complains of weight loss, racing heart rate, and
difficulty
sleeping. The nurse determines the client has moist skin with fine hair, prominent
eyes, lid
retraction, and a staring expression. These findings are consistent with which
disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome. - ANSWER: Grave's disease
RATIONALE:
This client is exhibiting symptoms associated with hyperthyroidism or Grave's
disease (A),
which is an autoimmune condition affecting the thyroid. (B, C, and D) are not
associated with
these symptoms.
The nurse is assessing an older client and determines that the client's left upper
eyelid droops,
covering more of the iris than the right eyelid. Which description should the nurse
use to
document this finding?
A. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - ANSWER: Ptosis on the left eyelid
Rationale: Ptosis is the term to describe an eyelid droop that covers a large portion
of the iris (A), which
may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by
rapid,
rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing
decreased
visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs
with
hyperthyroidism.
, The nurse is assessing a child's weight and height during a clinic visit prior to starting
school.
The nurse plots the child's weight on the growth chart and notes that the child's
weight is in the
95th percentile for the child's height. What action should the nurse take?
A. Question the type and quantity of foods eaten in a typical day.
B. Encourage giving two additional snacks each day to the child.
C. Recommend a daily intake of at least four glasses of whole milk.
D. Assess for signs of poor nutrition, such as a pale appearance - ANSWER: A.
Question the type and quantity of foods eaten in a typical day.
RATIONALE:
The child is overweight for height, so assessment of the child's daily diet (C) should
be
determined. The child does not need (A or B), both of which will increase the child's
weight.
Poor nutrition (D) is commonly seen in underweight children, not overweight.
A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 mL for the
first 10
kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How
many
milliliters per hour should the nurse program the infusion pump for a child who
weighs 19.5 kg?
(Enter numeric value only. If rounding is required, round to the nearest whole
number.)
A. 24
B. 61
C. 73
D. 58 - ANSWER: B. 61
RATIONALE:
The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day;
or 10 to
20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each
kilogram
between 10 and 20. To determine an hourly rate, divide the total milliliters per day
by 24. 19.5
kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour
The nurse obtains the pulse rate of 89 beats/minute for an infant before
administering digoxin
(Lanoxin). Which action should the nurse take?
A. Withhold the medication and contact the healthcare provider.
B. Give the medication dosage as scheduled.
C. Assess respiratory rate for one minute next.
D. Wait 30 minutes and give half of the dosage of medication. - ANSWER: A.
Withhold the medication and contact the healthcare provider
RATIONALE:
CARE HESI EXIT EXAM 2023 ACTUAL EXAM
A 56-year-old female client is receiving intracavitary radiation via a radium implant.
Which
nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary radiation.
B. A nurse with Marfan's syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium difficile. - ANSWER:
B. A nurse with Marfan's syndrome who is postmenopausal.
RATIONALE:
A client receiving intracavity radiation poses a radiation hazard as long as the
intracavity
radiation source is in place. A nurse's ability to care of this client is not affected by
Marfan's
syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles,
ligaments
and skeletal structures. The goal is to limit any one staff member's exposure to the
calculated
time span based on the half-life of radium, such as the number of minutes at the
bedside per day,
so (A) should not be assigned. (C) should not be exposed to the radiation due to the
possible
effect on the fetus. A radiation exposure decreases the immune response in the
client who should
not be exposed to the potential inadvertent transmission of an infectious organism
(D).
1.A client who has active tuberculosis (TB) is admitted to the medical unit. What
action is most
important for the nurse to implement?
A. Fit the client with a respirator mask.
B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway - ANSWER: Assign the client to a negative air-
flow room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client
should be
assigned to a negative pressure air-flow room (D). Although (A and C) should be
implemented
for clients in isolation with contact precautions, it is most important that air flow
from the room
,is minimized when the client has TB. (B) should be implemented when the client
leaves the
isolation environment.
2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction.
The nurse
determines the client's apical pulse is 65 beats per minute. What action should the
nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. - ANSWER: Administer the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce
the heart rate,
so the medication should be administered (C) because the client's apical pulse is
greater than 60.
(A, B, and D) are not indicated at this time.
3.The nurse is assessing a client and identifies a bruit over the thyroid. This finding is
consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism - ANSWER: Hyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred
to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in glandular vascularity
which
increases as the thyroid gland becomes hyperactive. A bruit is not common with (A,
B, and C).
A 6-year-old child is alert but quiet when brought to the emergency center with
periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential
child abuse and continues to assess the child for additional manifestations of a
basilar skull fracture. What
assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ANSWER: Rhinorrhoea or
otorrhoea with Halo sign.
RATIONALE:
,Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear
over the
mastoid process) are both signs of a basilar skull fracture, so the nurse should assess
for possible
meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose
(D). (A) is
consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder
or arm
fractures. (C) occurs with blunt abdominal injuries.
The nurse is assessing a client who complains of weight loss, racing heart rate, and
difficulty
sleeping. The nurse determines the client has moist skin with fine hair, prominent
eyes, lid
retraction, and a staring expression. These findings are consistent with which
disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome. - ANSWER: Grave's disease
RATIONALE:
This client is exhibiting symptoms associated with hyperthyroidism or Grave's
disease (A),
which is an autoimmune condition affecting the thyroid. (B, C, and D) are not
associated with
these symptoms.
The nurse is assessing an older client and determines that the client's left upper
eyelid droops,
covering more of the iris than the right eyelid. Which description should the nurse
use to
document this finding?
A. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid.
D. Astigmatism on the right. - ANSWER: Ptosis on the left eyelid
Rationale: Ptosis is the term to describe an eyelid droop that covers a large portion
of the iris (A), which
may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by
rapid,
rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing
decreased
visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs
with
hyperthyroidism.
, The nurse is assessing a child's weight and height during a clinic visit prior to starting
school.
The nurse plots the child's weight on the growth chart and notes that the child's
weight is in the
95th percentile for the child's height. What action should the nurse take?
A. Question the type and quantity of foods eaten in a typical day.
B. Encourage giving two additional snacks each day to the child.
C. Recommend a daily intake of at least four glasses of whole milk.
D. Assess for signs of poor nutrition, such as a pale appearance - ANSWER: A.
Question the type and quantity of foods eaten in a typical day.
RATIONALE:
The child is overweight for height, so assessment of the child's daily diet (C) should
be
determined. The child does not need (A or B), both of which will increase the child's
weight.
Poor nutrition (D) is commonly seen in underweight children, not overweight.
A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 mL for the
first 10
kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How
many
milliliters per hour should the nurse program the infusion pump for a child who
weighs 19.5 kg?
(Enter numeric value only. If rounding is required, round to the nearest whole
number.)
A. 24
B. 61
C. 73
D. 58 - ANSWER: B. 61
RATIONALE:
The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day;
or 10 to
20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each
kilogram
between 10 and 20. To determine an hourly rate, divide the total milliliters per day
by 24. 19.5
kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour
The nurse obtains the pulse rate of 89 beats/minute for an infant before
administering digoxin
(Lanoxin). Which action should the nurse take?
A. Withhold the medication and contact the healthcare provider.
B. Give the medication dosage as scheduled.
C. Assess respiratory rate for one minute next.
D. Wait 30 minutes and give half of the dosage of medication. - ANSWER: A.
Withhold the medication and contact the healthcare provider
RATIONALE:
