2025/2026 HESI RN CRITICAL CARE /CRITICAL CARE RN HESI EXIT
ACTUAL EXAM TEST BANK/ QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
Question 1
Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to
water seal. The client is using the incentive spirometer hourly while awake. Which assessment
finding warrants intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness.
Correct Answer: c) Water seal level 2 cm below the water seal fill line.
Rationale: The water seal chamber must be filled to the 2 cm line to maintain the proper
negative pressure. A level below this line compromises the seal, allowing air to re-enter the
pleural or mediastinal space, which requires immediate correction.
Question 2
A client with a demand pacemaker has a telemetry tracing with a pacing spike but no
corresponding QRS complex. The client's myocardium is eliciting a QRS after a delay of several
seconds. Which telemetry interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer.
Correct Answer: a) Loss of capture.
Rationale: "Capture" means the pacemaker's electrical stimulus successfully depolarizes
the myocardium, creating a QRS complex. "Loss of capture" occurs when the pacing spike
is not followed by a QRS, indicating the stimulus was not strong enough to be captured by
the heart muscle.
,Question 3
The nurse is caring for a client who underwent surgical repair of the abdominal aorta. Which
finding best indicates improved arterial blood flow to the lower body after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50 mmHg.
Correct Answer: a) Movement of lower extremities.
Rationale: Aortic surgery carries a risk of compromising blood flow to the spinal cord and
lower extremities. The return of motor function (movement) and sensation in the lower
extremities is a key indicator that perfusion has been successfully restored.
Question 4
When a nurse is reporting findings to a healthcare provider using the SBAR format, which
statement best represents the "Recommendation" part of the report?
a) "I am requesting a prescription for an additional respiratory treatment."
b) "The client was admitted today with difficulty breathing."
c) "The client has a history of COPD."
d) "The client has expiratory wheezes in the lower lobes."
Correct Answer: a) "I am requesting a prescription for an additional respiratory
treatment."
Rationale: The 'R' in SBAR stands for Recommendation. This is where the nurse clearly
and concisely states what they believe is needed for the patient, such as a new order, a
consultation, or a change in the plan of care.
Question 5
A client is receiving mechanical ventilation. The family asks when the client will be extubated.
Which information should the nurse provide as a key criterion for weaning?
a) The client's ability to breathe spontaneously in between mechanical ventilations.
b) Normalization of all serum electrolyte and blood chemistry levels.
c) Completion of intravenous antibiotic therapy.
d) Resolution of inflammation on the chest x-ray.
,Correct Answer: a) The client's ability to breathe spontaneously in between mechanical
ventilations.
Rationale: The decision to wean from mechanical ventilation is primarily based on the
client's ability to breathe on their own. This is assessed through spontaneous breathing
trials (SBTs) where the ventilator support is temporarily reduced or stopped.
Question 6
A client with severe sepsis has uneven, labored respirations. ABG results show respiratory
alkalosis (pH 7.60, PaCO2 25 mmHg). Which assessment finding warrants immediate
intervention?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds.
Correct Answer: b) Intercostal muscle retraction.
Rationale: Intercostal muscle retraction is a sign of severe respiratory distress and
impending respiratory muscle fatigue. This indicates that the client is working very hard to
breathe and is at high risk for acute respiratory failure, requiring immediate intervention
such as intubation.
Question 7
A client receiving an IV infusion of dopamine through a peripheral line reports burning at the IV
site. Which action should the nurse implement first?
a) Stop the infusion and notify the healthcare provider.
b) Check the line for blood return and flush the catheter.
c) Apply a cold compress to the site.
d) Slow the infusion rate.
Correct Answer: a) Stop the infusion and notify the healthcare provider.
Rationale: Dopamine is a potent vasopressor that can cause severe tissue necrosis if it
extravasates (leaks into the surrounding tissue). Burning at the site is a key sign of
extravasation. The infusion must be stopped immediately to prevent further damage, and
the provider must be notified.
, Question 8
The nurse is analyzing an arterial blood gas (ABG) with the following results: pH 7.17, PaCO2
70 mmHg, HCO3 30 mEq/L. How should the nurse interpret this ABG?
a) Partially compensated respiratory acidosis.
b) Respiratory alkalosis.
c) Metabolic acidosis.
d) Metabolic alkalosis.
Correct Answer: a) Partially compensated respiratory acidosis.
Rationale: The pH is low (acidosis). The PaCO2 is high, which causes respiratory acidosis.
The HCO3 is high, which is the kidneys' compensatory response to the high CO2. Because
the pH is still abnormal, the compensation is only partial.
Question 9
A client with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. Which
intervention should the nurse prepare for?
a) Intubation with mechanical ventilation.
b) Nasogastric tube placement.
c) Administration of a thrombolytic.
d) Application of a cervical collar.
Correct Answer: a) Intubation with mechanical ventilation.
Rationale: A GCS score of 8 or less typically indicates a severe head injury and an inability
to protect one's own airway. Intubation and mechanical ventilation are necessary to secure
the airway and support breathing.
Question 10
A client has a GCS score of 3, fixed and dilated pupils, and hypotension. The spouse asks when
the client will wake up. How should the nurse respond?
a) "Your spouse's condition indicates irreversible brain damage."
b) "Let me contact the healthcare provider to answer your questions."
c) "We need to wait and see what happens."
d) "We will try warming blankets to stimulate a response."
Correct Answer: b) "Let me contact the healthcare provider to answer your questions."
ACTUAL EXAM TEST BANK/ QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
Question 1
Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to
water seal. The client is using the incentive spirometer hourly while awake. Which assessment
finding warrants intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness.
Correct Answer: c) Water seal level 2 cm below the water seal fill line.
Rationale: The water seal chamber must be filled to the 2 cm line to maintain the proper
negative pressure. A level below this line compromises the seal, allowing air to re-enter the
pleural or mediastinal space, which requires immediate correction.
Question 2
A client with a demand pacemaker has a telemetry tracing with a pacing spike but no
corresponding QRS complex. The client's myocardium is eliciting a QRS after a delay of several
seconds. Which telemetry interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer.
Correct Answer: a) Loss of capture.
Rationale: "Capture" means the pacemaker's electrical stimulus successfully depolarizes
the myocardium, creating a QRS complex. "Loss of capture" occurs when the pacing spike
is not followed by a QRS, indicating the stimulus was not strong enough to be captured by
the heart muscle.
,Question 3
The nurse is caring for a client who underwent surgical repair of the abdominal aorta. Which
finding best indicates improved arterial blood flow to the lower body after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50 mmHg.
Correct Answer: a) Movement of lower extremities.
Rationale: Aortic surgery carries a risk of compromising blood flow to the spinal cord and
lower extremities. The return of motor function (movement) and sensation in the lower
extremities is a key indicator that perfusion has been successfully restored.
Question 4
When a nurse is reporting findings to a healthcare provider using the SBAR format, which
statement best represents the "Recommendation" part of the report?
a) "I am requesting a prescription for an additional respiratory treatment."
b) "The client was admitted today with difficulty breathing."
c) "The client has a history of COPD."
d) "The client has expiratory wheezes in the lower lobes."
Correct Answer: a) "I am requesting a prescription for an additional respiratory
treatment."
Rationale: The 'R' in SBAR stands for Recommendation. This is where the nurse clearly
and concisely states what they believe is needed for the patient, such as a new order, a
consultation, or a change in the plan of care.
Question 5
A client is receiving mechanical ventilation. The family asks when the client will be extubated.
Which information should the nurse provide as a key criterion for weaning?
a) The client's ability to breathe spontaneously in between mechanical ventilations.
b) Normalization of all serum electrolyte and blood chemistry levels.
c) Completion of intravenous antibiotic therapy.
d) Resolution of inflammation on the chest x-ray.
,Correct Answer: a) The client's ability to breathe spontaneously in between mechanical
ventilations.
Rationale: The decision to wean from mechanical ventilation is primarily based on the
client's ability to breathe on their own. This is assessed through spontaneous breathing
trials (SBTs) where the ventilator support is temporarily reduced or stopped.
Question 6
A client with severe sepsis has uneven, labored respirations. ABG results show respiratory
alkalosis (pH 7.60, PaCO2 25 mmHg). Which assessment finding warrants immediate
intervention?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds.
Correct Answer: b) Intercostal muscle retraction.
Rationale: Intercostal muscle retraction is a sign of severe respiratory distress and
impending respiratory muscle fatigue. This indicates that the client is working very hard to
breathe and is at high risk for acute respiratory failure, requiring immediate intervention
such as intubation.
Question 7
A client receiving an IV infusion of dopamine through a peripheral line reports burning at the IV
site. Which action should the nurse implement first?
a) Stop the infusion and notify the healthcare provider.
b) Check the line for blood return and flush the catheter.
c) Apply a cold compress to the site.
d) Slow the infusion rate.
Correct Answer: a) Stop the infusion and notify the healthcare provider.
Rationale: Dopamine is a potent vasopressor that can cause severe tissue necrosis if it
extravasates (leaks into the surrounding tissue). Burning at the site is a key sign of
extravasation. The infusion must be stopped immediately to prevent further damage, and
the provider must be notified.
, Question 8
The nurse is analyzing an arterial blood gas (ABG) with the following results: pH 7.17, PaCO2
70 mmHg, HCO3 30 mEq/L. How should the nurse interpret this ABG?
a) Partially compensated respiratory acidosis.
b) Respiratory alkalosis.
c) Metabolic acidosis.
d) Metabolic alkalosis.
Correct Answer: a) Partially compensated respiratory acidosis.
Rationale: The pH is low (acidosis). The PaCO2 is high, which causes respiratory acidosis.
The HCO3 is high, which is the kidneys' compensatory response to the high CO2. Because
the pH is still abnormal, the compensation is only partial.
Question 9
A client with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. Which
intervention should the nurse prepare for?
a) Intubation with mechanical ventilation.
b) Nasogastric tube placement.
c) Administration of a thrombolytic.
d) Application of a cervical collar.
Correct Answer: a) Intubation with mechanical ventilation.
Rationale: A GCS score of 8 or less typically indicates a severe head injury and an inability
to protect one's own airway. Intubation and mechanical ventilation are necessary to secure
the airway and support breathing.
Question 10
A client has a GCS score of 3, fixed and dilated pupils, and hypotension. The spouse asks when
the client will wake up. How should the nurse respond?
a) "Your spouse's condition indicates irreversible brain damage."
b) "Let me contact the healthcare provider to answer your questions."
c) "We need to wait and see what happens."
d) "We will try warming blankets to stimulate a response."
Correct Answer: b) "Let me contact the healthcare provider to answer your questions."
