Critical Care Exit Hesi QUESTIONS WITH VERIFIED ANSWERS ..

Critical Care Exit Hesi
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The nurse cares for a client with 1

a cuffed tracheostomy tube.

Before performing oral care, the

nurse notes that the client's

tracheostomy cuff is inflated.

Which of the following is the

MOST appropriate action for the

nurse to take?

1. Leave the cuff inflated and

suction through the

tracheostomy.

2. Deflate the cuff and suction

through the tracheostomy tube.

3. Inflate the cuff pressure to 40

mm Hg before suctioning.

4. Adjust the wall suction

pressure to 160 to 180 mm Hg

before suctioning.


A young adult brings a friend to 2

the emergency department and

states that the friend has been

using heroin. Which action by

the nurse is the MOST

appropriate?

1. Assess pupil size and

reactivity.

2. Assess oxygen saturation

levels.

3. Palpate dorsalis pedis pulses.

4. Ask the client if he knows

today's date

,The client tells the clinic nurse 3

that the client is thinking about

using nicotine polacrilex

(Nicorette). Which question is

MOST important for the nurse to

ask?

1. "Have you tried other methods

to stop smoking?"

2. "How long have you been

smoking?"

3. "Have you ever had chest

pain?"

4. "Do you have a partial dental

bridge?"


The nurse cares for the client 4

with a client controlled

analgesia (PCA) pump. The

nurse determines that the client

has pressed the button 11 times

and received 6 doses of

morphine during the last hour.

Which is the MOST appropriate

action for the nurse to take?

1. Assess the patency of the PCA

IV tubing.

2. Determine the client's

understanding of the PCA pump

function.

3. Obtain an order to begin a

PCA infusion of fentanyl.

4. Ask the client to describe the

pain.


A pregnant woman receives an 3

epidural anesthetic. After

administration of the epidural

anesthetic, the client's blood

pressure changes from 120/84 to

94/50. Which action by the

nurse is MOST appropriate?

1. Place the client flat on her

back.

2. Elevate the head of the bed

30 degrees.

3. Place the client on her left

side with her legs flexed.

4. Place the client supine with

the foot of the bed elevated

, A nursing order, "Increase fluid 1

intake" is written for a client

diagnosed with dehydration.

Which finding BEST indicates

improving fluid status?

1. Urinary output of 1,500 mL in

24 hours.

2. Serum hematocrit 52%.

3. Oral fluid intake of 900 mL in

24 hours.

4. Blood pressure of 100/82.


The nurse prepares to 2

administer the initial dose of oral

enalapril (Vasotec) 20 mg in the

morning. Which medication

should the nurse question giving

to the client?

1. 20 mg oral escitalopram

(Celexa) in the morning.

2. 40 mg oral furosemide (Lasix)

in the morning.

3. 300 mg of oral gabapentin

(Neurontin) twice daily.

4. 10 mg zolpidem (Ambien) at

bedtime.


The home care nurse visits a 3

client with a halo fixator traction

device. Which client statement

MOST concerns the nurse?

1. "My wife looks at the pin sites

every day."

2. "I like to bathe in the tub."

3. "I drove to the library

yesterday."

4. "I drink with a straw."


the nurse cares for a client 1

diagnosed with depression.

Which statement by the client

indicates improvement?

1. "I have been sleeping 6 hours

at night."

2. "I have lost 2 lbs in the past

week."

3. "Lately, I have trouble

watching television."

4. "I have much less muscle

tension now."