HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
1. A 56-year-old female client is re- B. A nurse with Marfan's syndrome who is
post-
ceiving intracavitary radiation via a menopausal.
radium implant. Which RATIONALE:
nurse should be assigned to A client receiving intracavity radiation poses a
care for this client? radiation hazard as long as the intracavity
A. The nurse who is caring radiation source is in place. A nurse's ability to care
for an- other client receiving of this client is not attected by Marfan's
intracavitary radiation. syndrome (B), which is a hereditary disorder of
con-
B. A nurse with Marfan's syndrome nective tissues, bones, muscles,
ligaments
who is postmenopausal. and skeletal structures. The goal is to limit any one
C. A nurse with oncology statt member's exposure to the calculated
experi- ence who may be time span based on the half-life of radium, such as
pregnant. the number of minutes at the bedside per day,
D. The nurse who is caring for so (A) should not be assigned. (C) should not be
an- other client who has ex- posed to the radiation due to the possible
Clostridium difficile. ettect on the fetus. A radiation exposure decreases
the immune response in the client who should
not be exposed to the potential inadvertent
transmis- sion of an infectious organism (D).
2. 1.A client who has active tuberculo- Assign the client to a negative air-flow
room
sis (TB) is admitted to the negative air-flow room.
medical unit. What action is C. Don a clean gown for
most important for the nurse client care.
to imple- ment?
A. Fit the client with a
respirator mask.
B. Assign the client to a
, HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
RATIONALE:
Active tuberculosis requires implementation of air-
borne precautions, so the client should be
assigned to a negative pressure air-flow room (D).
Al- though (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.
, HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
D.Place an isolation cart in the
hall- way
3. 2.A client is receiving
Administer the medication
atenolol (Tenormin) 25 mg RATIONALE:
PO after a my- ocardial Atenolol, a beta-blocker, blocks the beta receptors
infarction. The nurse of
determines the client's apical pulse the sinoatrial node to reduce the heart
rate,
is 65 beats per minute. What action so the medication should be administered
(C) because
should the qui-
nurse
implement
next?
A. Measure the blood
pressure.
B. Reassess the apical pulse.
C. Notify the healthcare
provider.
D. Administer the medication.
4. 3.The nurse is assessing a
client and identifies a bruit
over the thy- roid. This
finding is consistent with
which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism
5. A 6-year-old child is alert but
, HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
the client's apical pulse is greater than 60. Rationale:Hyperthyroidism (D) is an enlargement
(A, B, and D) are not indicated at this of the thyroid gland, often referred to as a
time. 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).
Hyperthyroidism
Rhinorrhoea or otorrhoea with Halo sign.
et when brought to the emergency RATIONALE:
center with periorbital Raccoon eyes (periorbital ecchymosis) and
ecchymosis and ecchymosis Battle's sign (ecchymosis behind the ear over
behind the ears. the
The nurse suspects potential mastoid process) are both signs of a basilar
child abuse and continues to skull frac- ture, so the nurse should assess for
assess the child for additional possible meningeal tears that manifest as a
manifestations Halo sign with CSF
VERIFIED ANSWERS (UPDATED TO PASS)
1. A 56-year-old female client is re- B. A nurse with Marfan's syndrome who is
post-
ceiving intracavitary radiation via a menopausal.
radium implant. Which RATIONALE:
nurse should be assigned to A client receiving intracavity radiation poses a
care for this client? radiation hazard as long as the intracavity
A. The nurse who is caring radiation source is in place. A nurse's ability to care
for an- other client receiving of this client is not attected by Marfan's
intracavitary radiation. syndrome (B), which is a hereditary disorder of
con-
B. A nurse with Marfan's syndrome nective tissues, bones, muscles,
ligaments
who is postmenopausal. and skeletal structures. The goal is to limit any one
C. A nurse with oncology statt member's exposure to the calculated
experi- ence who may be time span based on the half-life of radium, such as
pregnant. the number of minutes at the bedside per day,
D. The nurse who is caring for so (A) should not be assigned. (C) should not be
an- other client who has ex- posed to the radiation due to the possible
Clostridium difficile. ettect on the fetus. A radiation exposure decreases
the immune response in the client who should
not be exposed to the potential inadvertent
transmis- sion of an infectious organism (D).
2. 1.A client who has active tuberculo- Assign the client to a negative air-flow
room
sis (TB) is admitted to the negative air-flow room.
medical unit. What action is C. Don a clean gown for
most important for the nurse client care.
to imple- ment?
A. Fit the client with a
respirator mask.
B. Assign the client to a
, HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
RATIONALE:
Active tuberculosis requires implementation of air-
borne precautions, so the client should be
assigned to a negative pressure air-flow room (D).
Al- though (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.
, HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
D.Place an isolation cart in the
hall- way
3. 2.A client is receiving
Administer the medication
atenolol (Tenormin) 25 mg RATIONALE:
PO after a my- ocardial Atenolol, a beta-blocker, blocks the beta receptors
infarction. The nurse of
determines the client's apical pulse the sinoatrial node to reduce the heart
rate,
is 65 beats per minute. What action so the medication should be administered
(C) because
should the qui-
nurse
implement
next?
A. Measure the blood
pressure.
B. Reassess the apical pulse.
C. Notify the healthcare
provider.
D. Administer the medication.
4. 3.The nurse is assessing a
client and identifies a bruit
over the thy- roid. This
finding is consistent with
which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism
5. A 6-year-old child is alert but
, HESI CRITICAL CARE EXAM WITH ALL CORRECT &
VERIFIED ANSWERS (UPDATED TO PASS)
the client's apical pulse is greater than 60. Rationale:Hyperthyroidism (D) is an enlargement
(A, B, and D) are not indicated at this of the thyroid gland, often referred to as a
time. 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).
Hyperthyroidism
Rhinorrhoea or otorrhoea with Halo sign.
et when brought to the emergency RATIONALE:
center with periorbital Raccoon eyes (periorbital ecchymosis) and
ecchymosis and ecchymosis Battle's sign (ecchymosis behind the ear over
behind the ears. the
The nurse suspects potential mastoid process) are both signs of a basilar
child abuse and continues to skull frac- ture, so the nurse should assess for
assess the child for additional possible meningeal tears that manifest as a
manifestations Halo sign with CSF
