HESI RN CRITICAL CARE /CRITICAL CARE RN
HESI EXIT ACTUAL EXAM TEST BANK LATEST
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
the nurse is assigned to care for a client with IV fluids
infusing at 100ml/hr and a NG tube with enteral
feedings infusing at 60mL/hr. the client is
mechanically ventilated with 40% FiO2. PIP was 24cm
H2O fours ago and is now 62 cm H2O. which
interventions should the nurse implement?
a. suction the endotracheal tube
b. decrease the IV to 50ml/he
c. turn off the enteral feedings
d. increase the FiO2 to 100%
suction the endotracheal tube
the nurse is analyzing an ABG of client who is
mechanically ventilated. the results are pH 7.17,
PaCO2 70, HCO3 20. the nurse would understand that
which is likely the cause of these results?
a. respiratory rate is too slow, causing respiratory
acidosis
b. respiratory rate is too rapid, causing respiratory
alkalosis
c. diarrhea has caused metabolic acidosis
d. vomiting has caused metabolic alkalosis
diarrhea has caused metabolic acidosis
a client is admitted to the ICU with hematemesis
related to esophageal varices. which assessment
,finding should the nurse identify that is the result of
an estimated blood loss at 35% of total blood volume?
a. absent bowel sounds
b. coma
c. anuria
d. abdominal pain
absent bowel sounds
the nurse is caring for a client in the surgical ICU who
received a bone marrow transplant. which finding
should the nurse report to the HCP that indicates the
possible onset of graft versus host disease?
a. jaundice
b. polyuria
c. bradycardia
d. constipation
jaundice
a client with DKA is admitted to the ICU. which ABG
reflects Kussmaul respiratory pattern?
a. pH 7.22, CO2 31, pO2 138, HCO3 14
b. pH 7.58, CO2 28, PO2 128, HCP3 25
c. pH 7.40, CO2 45, PO2 138, HCO3 25
d. pH 7.01, CO2 28, PO2 99, HCP3 22
pH 7.22, CO2 31, pO2 138, HCO3 14
the nurse applies external self adhesive pacemaker
pads to the chest of a client who has symptomatic
bradycardia that has been unresponsive to several
doses of Atropine. the nurse is setting the pacemaker
rate and level of energy. which nursing intervention is
most important when setting the pacemaker to obtain
myocardial capture?
a. slowly increases the mA setting until capture is
,present
b. set the mA an additional 2 mA above where the
capture began
c. put the pacemaker in the demand mode
d. program the pacemaker rate to match the clients
intrinsic rate
slowly increases the mA setting until capture is present
a client in the ICU begins to manifest seizure activity
while the UAP is providing a bed bath. the UAP pulls
the emergency call bell and calls for help. which
action by the UAP should the nurse correct?
a. restraining the clients extremities
b. loosening restrictive clothing
c. padding the raised side rails
d. placing the client in a lateral position
loosening restrictive clothing
an ICU client is extubated and placed on 40% oxygen
via face mask. the nurse finds the client confused and
attempting to get out of bed. in shift report it was
noted that client has not been sleeping. oxygen
saturation is 96%. which intervention should the nurse
implement?
a. administer a PRN IV sedative
b. change to partial rebreather mask
c. limit visitors to immediate family
d. apply bilateral soft wrist restraints
administer a PRN IV sedative
the nurse is monitoring the renal function of a client in
the ICU. the client is receiving vancomycin and
ceftriaxone for sepsis. which finding indicates the
onset of AKI?
, a. serum creatinine 2.8
b. cloudy malodorous urine
c. urine output 1000mL/24 hours
d. peripheral edema of lower extremities
serum creatinine 2.8
a client with a history of chronic alcoholism is
admitted with pneumonia. the nurse inserts two large
bore IV catheters and starts an infusion of 0.9%
sodium chloride at 75ml/hr and titrates the clients
oxygen to 60% by nonrebreather mask. the cardiac
monitor displays sinus tachycardia with multifocal
PVCs. which clients serum lab values requires
immediate intervention by the nurse?
a. sodium 138
b. hemoglobin 9
c. magnesium 1.0
d. potassium 5.5
magnesium 1.0
the nurse is caring for a client admitted to the surgical
ICU after undergoing GI surgery. which intervention
should the nurse include in the plan of care to
minimize the risk for vomiting?
a. maintain patency of NGT to low intermittent suction
b. provide soft, bland diet with oral liquids
c. initiate dextrose 5% in LR IV at 125 mL/hour
d. insert a rectal tube followed with progressive
mobilization techniques
maintain patency of NGT to low intermittent suction
a client is admitted to the ICU with hepatic
encephalopathy secondary to cirrhosis. the client is
lethargic and confused. the healthcare provider
HESI EXIT ACTUAL EXAM TEST BANK LATEST
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+
the nurse is assigned to care for a client with IV fluids
infusing at 100ml/hr and a NG tube with enteral
feedings infusing at 60mL/hr. the client is
mechanically ventilated with 40% FiO2. PIP was 24cm
H2O fours ago and is now 62 cm H2O. which
interventions should the nurse implement?
a. suction the endotracheal tube
b. decrease the IV to 50ml/he
c. turn off the enteral feedings
d. increase the FiO2 to 100%
suction the endotracheal tube
the nurse is analyzing an ABG of client who is
mechanically ventilated. the results are pH 7.17,
PaCO2 70, HCO3 20. the nurse would understand that
which is likely the cause of these results?
a. respiratory rate is too slow, causing respiratory
acidosis
b. respiratory rate is too rapid, causing respiratory
alkalosis
c. diarrhea has caused metabolic acidosis
d. vomiting has caused metabolic alkalosis
diarrhea has caused metabolic acidosis
a client is admitted to the ICU with hematemesis
related to esophageal varices. which assessment
,finding should the nurse identify that is the result of
an estimated blood loss at 35% of total blood volume?
a. absent bowel sounds
b. coma
c. anuria
d. abdominal pain
absent bowel sounds
the nurse is caring for a client in the surgical ICU who
received a bone marrow transplant. which finding
should the nurse report to the HCP that indicates the
possible onset of graft versus host disease?
a. jaundice
b. polyuria
c. bradycardia
d. constipation
jaundice
a client with DKA is admitted to the ICU. which ABG
reflects Kussmaul respiratory pattern?
a. pH 7.22, CO2 31, pO2 138, HCO3 14
b. pH 7.58, CO2 28, PO2 128, HCP3 25
c. pH 7.40, CO2 45, PO2 138, HCO3 25
d. pH 7.01, CO2 28, PO2 99, HCP3 22
pH 7.22, CO2 31, pO2 138, HCO3 14
the nurse applies external self adhesive pacemaker
pads to the chest of a client who has symptomatic
bradycardia that has been unresponsive to several
doses of Atropine. the nurse is setting the pacemaker
rate and level of energy. which nursing intervention is
most important when setting the pacemaker to obtain
myocardial capture?
a. slowly increases the mA setting until capture is
,present
b. set the mA an additional 2 mA above where the
capture began
c. put the pacemaker in the demand mode
d. program the pacemaker rate to match the clients
intrinsic rate
slowly increases the mA setting until capture is present
a client in the ICU begins to manifest seizure activity
while the UAP is providing a bed bath. the UAP pulls
the emergency call bell and calls for help. which
action by the UAP should the nurse correct?
a. restraining the clients extremities
b. loosening restrictive clothing
c. padding the raised side rails
d. placing the client in a lateral position
loosening restrictive clothing
an ICU client is extubated and placed on 40% oxygen
via face mask. the nurse finds the client confused and
attempting to get out of bed. in shift report it was
noted that client has not been sleeping. oxygen
saturation is 96%. which intervention should the nurse
implement?
a. administer a PRN IV sedative
b. change to partial rebreather mask
c. limit visitors to immediate family
d. apply bilateral soft wrist restraints
administer a PRN IV sedative
the nurse is monitoring the renal function of a client in
the ICU. the client is receiving vancomycin and
ceftriaxone for sepsis. which finding indicates the
onset of AKI?
, a. serum creatinine 2.8
b. cloudy malodorous urine
c. urine output 1000mL/24 hours
d. peripheral edema of lower extremities
serum creatinine 2.8
a client with a history of chronic alcoholism is
admitted with pneumonia. the nurse inserts two large
bore IV catheters and starts an infusion of 0.9%
sodium chloride at 75ml/hr and titrates the clients
oxygen to 60% by nonrebreather mask. the cardiac
monitor displays sinus tachycardia with multifocal
PVCs. which clients serum lab values requires
immediate intervention by the nurse?
a. sodium 138
b. hemoglobin 9
c. magnesium 1.0
d. potassium 5.5
magnesium 1.0
the nurse is caring for a client admitted to the surgical
ICU after undergoing GI surgery. which intervention
should the nurse include in the plan of care to
minimize the risk for vomiting?
a. maintain patency of NGT to low intermittent suction
b. provide soft, bland diet with oral liquids
c. initiate dextrose 5% in LR IV at 125 mL/hour
d. insert a rectal tube followed with progressive
mobilization techniques
maintain patency of NGT to low intermittent suction
a client is admitted to the ICU with hepatic
encephalopathy secondary to cirrhosis. the client is
lethargic and confused. the healthcare provider
