NR 340 HESI Critical Care Nursing Final
Exam 2025| 160 Questions and Verified
Correct Answers
While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on
the client’s legs. What additional assessment provides further data to support this finding?
A. Palpate for pulse strength in the pedal arteries.
B. Assess for discoloration of the toenails.
C. Inspect the skin for petechiae or bruising.
D. Measure the circumference of the calves.
Correct Answer: A. Palpate for pulse strength in the pedal arteries.
Explanation: Absence of hair growth on the legs in a client with diabetes mellitus may
indicate poor peripheral circulation, a common complication due to peripheral vascular disease.
Palpating pedal pulses provides additional data about blood flow to the lower extremities,
supporting the finding of potential circulatory impairment.
The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant
receive?
A. 27.3 mg
B. 60 mg
C. 13.6 mg
D. 30 mg
Correct Answer: A. 27.3 mg
Explanation: First, convert the infant’s weight from pounds to kilograms: 4 pounds ÷ 2.2 =
1.82 kg. Then, calculate the dose: 15 mg/kg × 1.82 kg = 27.3 mg. The drug is diluted in 25 ml of
D5W, but the total dose of Streptomycin is based on the weight calculation, not the infusion
volume or rate.
In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines
that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml
in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should
the nurse implement?
,A. Continue monitoring and document findings.
B. Stop the magnesium sulfate infusion immediately.
C. Administer calcium gluconate as an antidote.
D. Increase the magnesium sulfate infusion rate.
Correct Answer: B. Stop the magnesium sulfate infusion immediately.
Explanation: A magnesium sulfate level of 9 mg/dl is above the therapeutic range (4–8
mg/dl), indicating potential toxicity. Signs such as diminished deep tendon reflexes (1+), low
respiratory rate (12 breaths/minute), and low urinary output (90 ml in 4 hours) further suggest
magnesium toxicity. The nurse should stop the infusion to prevent further complications.
A client is on a mechanical ventilator. Which client response indicates that the neuromuscular
blocker tubocurarine chloride (Tubarine) is effective?
A. The client’s respiratory rate increases.
B. The client does not trigger the ventilator alarms.
C. The client exhibits spontaneous limb movement.
D. The client responds to verbal stimuli.
Correct Answer: B. The client does not trigger the ventilator alarms.
Explanation: Tubocurarine is a neuromuscular blocker that causes paralysis to facilitate
mechanical ventilation by preventing patient-ventilator asynchrony. If the medication is
effective, the client will not resist or trigger the ventilator, resulting in no alarms being activated.
An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that
she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint
pain. Based on this client’s comment, what previous lab values should the nurse compare with
today’s lab report?
A. Complete blood count (CBC).
B. Liver function tests (LFTs).
C. Renal function tests.
D. Blood glucose levels.
Correct Answer: B. Liver function tests (LFTs).
Explanation: Acetaminophen overdose or prolonged high doses can cause hepatotoxicity.
Comparing current liver function tests (e.g., AST, ALT, bilirubin) with previous results helps
assess for liver damage, which is critical given the client’s increased acetaminophen use.
,Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory
process, promote comfort, and reduce fever. What intervention is most important for the nurse to
implement?
A. Monitor for signs of salicylate toxicity.
B. Administer the aspirin with food.
C. Assess the child’s temperature hourly.
D. Encourage fluid intake to prevent dehydration.
Correct Answer: A. Monitor for signs of salicylate toxicity.
Explanation: Aspirin in children, especially for conditions like rheumatic fever, carries a risk
of salicylate toxicity, which can manifest as tinnitus, hyperventilation, or metabolic acidosis.
Monitoring for these signs is critical to ensure the child’s safety.
Which signs or symptoms are characteristic of an adult client diagnosed with Cushing’s
syndrome?
A. Weight loss, hypotension, and hypoglycemia.
B. Moon face, buffalo hump, and truncal obesity.
C. Bradycardia, dry skin, and constipation.
D. Tremors, nervousness, and exophthalmos.
Correct Answer: B. Moon face, buffalo hump, and truncal obesity.
Explanation: Cushing’s syndrome is caused by excess cortisol, leading to characteristic
symptoms such as moon face, buffalo hump (fat pad at the upper back), and truncal obesity.
These are hallmark physical findings due to fat redistribution.
A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the
status report provided by the nurse who is leaving for lunch, which client should be checked first
by the charge nurse? The client
A. with a history of asthma who is receiving oxygen at 2 liters per minute.
B. postoperative from an appendectomy with stable vital signs.
C. with chest pain and new-onset arrhythmias.
D. with diabetes mellitus receiving insulin via infusion pump.
Correct Answer: C. with chest pain and new-onset arrhythmias.
Explanation: Chest pain with new-onset arrhythmias indicates a potentially life-threatening
condition, such as acute coronary syndrome or cardiac instability, requiring immediate
assessment and intervention.
, An outcome for treatment of peripheral vascular disease is, “The client will have decreased
venous congestion.” What client behavior would indicate to the nurse that this outcome has been
met?
A. The client elevates the legs when sitting.
B. The client avoids tight clothing on the legs.
C. The client walks daily for 30 minutes.
D. The client applies moisturizer to dry skin.
Correct Answer: A. The client elevates the legs when sitting.
Explanation: Elevating the legs promotes venous return and reduces venous congestion,
directly addressing the outcome. Other options may support general vascular health but do not
specifically target venous congestion.
The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are
removed. Which assessment parameter is most critical for the nurse to monitor following the
procedure?
A. Blood pressure.
B. Serum sodium levels.
C. Abdominal girth.
D. Respiratory rate.
Correct Answer: A. Blood pressure.
Explanation: Removing a large volume of fluid (3 liters) during paracentesis can cause a rapid
shift in intravascular volume, potentially leading to hypotension. Monitoring blood pressure is
critical to detect and manage this complication.
The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal
disease (ESRD). The client asks the nurse to bring the medication later. The nurse should
describe which action of RenaGel as an explanation for taking it with meals?
A. It reduces nausea associated with meals.
B. It binds phosphates in the gastrointestinal tract.
C. It enhances absorption of dietary calcium.
D. It prevents gastric irritation from other medications.
Correct Answer: B. It binds phosphates in the gastrointestinal tract.
Explanation: Sevelamer is a phosphate binder used in ESRD to reduce serum phosphate
levels by binding dietary phosphates in the gut, preventing their absorption. Taking it with meals
maximizes its effectiveness.
Exam 2025| 160 Questions and Verified
Correct Answers
While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on
the client’s legs. What additional assessment provides further data to support this finding?
A. Palpate for pulse strength in the pedal arteries.
B. Assess for discoloration of the toenails.
C. Inspect the skin for petechiae or bruising.
D. Measure the circumference of the calves.
Correct Answer: A. Palpate for pulse strength in the pedal arteries.
Explanation: Absence of hair growth on the legs in a client with diabetes mellitus may
indicate poor peripheral circulation, a common complication due to peripheral vascular disease.
Palpating pedal pulses provides additional data about blood flow to the lower extremities,
supporting the finding of potential circulatory impairment.
The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant
receive?
A. 27.3 mg
B. 60 mg
C. 13.6 mg
D. 30 mg
Correct Answer: A. 27.3 mg
Explanation: First, convert the infant’s weight from pounds to kilograms: 4 pounds ÷ 2.2 =
1.82 kg. Then, calculate the dose: 15 mg/kg × 1.82 kg = 27.3 mg. The drug is diluted in 25 ml of
D5W, but the total dose of Streptomycin is based on the weight calculation, not the infusion
volume or rate.
In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines
that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml
in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should
the nurse implement?
,A. Continue monitoring and document findings.
B. Stop the magnesium sulfate infusion immediately.
C. Administer calcium gluconate as an antidote.
D. Increase the magnesium sulfate infusion rate.
Correct Answer: B. Stop the magnesium sulfate infusion immediately.
Explanation: A magnesium sulfate level of 9 mg/dl is above the therapeutic range (4–8
mg/dl), indicating potential toxicity. Signs such as diminished deep tendon reflexes (1+), low
respiratory rate (12 breaths/minute), and low urinary output (90 ml in 4 hours) further suggest
magnesium toxicity. The nurse should stop the infusion to prevent further complications.
A client is on a mechanical ventilator. Which client response indicates that the neuromuscular
blocker tubocurarine chloride (Tubarine) is effective?
A. The client’s respiratory rate increases.
B. The client does not trigger the ventilator alarms.
C. The client exhibits spontaneous limb movement.
D. The client responds to verbal stimuli.
Correct Answer: B. The client does not trigger the ventilator alarms.
Explanation: Tubocurarine is a neuromuscular blocker that causes paralysis to facilitate
mechanical ventilation by preventing patient-ventilator asynchrony. If the medication is
effective, the client will not resist or trigger the ventilator, resulting in no alarms being activated.
An elderly female client comes to the clinic for a regular check-up. The client tells the nurse that
she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint
pain. Based on this client’s comment, what previous lab values should the nurse compare with
today’s lab report?
A. Complete blood count (CBC).
B. Liver function tests (LFTs).
C. Renal function tests.
D. Blood glucose levels.
Correct Answer: B. Liver function tests (LFTs).
Explanation: Acetaminophen overdose or prolonged high doses can cause hepatotoxicity.
Comparing current liver function tests (e.g., AST, ALT, bilirubin) with previous results helps
assess for liver damage, which is critical given the client’s increased acetaminophen use.
,Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory
process, promote comfort, and reduce fever. What intervention is most important for the nurse to
implement?
A. Monitor for signs of salicylate toxicity.
B. Administer the aspirin with food.
C. Assess the child’s temperature hourly.
D. Encourage fluid intake to prevent dehydration.
Correct Answer: A. Monitor for signs of salicylate toxicity.
Explanation: Aspirin in children, especially for conditions like rheumatic fever, carries a risk
of salicylate toxicity, which can manifest as tinnitus, hyperventilation, or metabolic acidosis.
Monitoring for these signs is critical to ensure the child’s safety.
Which signs or symptoms are characteristic of an adult client diagnosed with Cushing’s
syndrome?
A. Weight loss, hypotension, and hypoglycemia.
B. Moon face, buffalo hump, and truncal obesity.
C. Bradycardia, dry skin, and constipation.
D. Tremors, nervousness, and exophthalmos.
Correct Answer: B. Moon face, buffalo hump, and truncal obesity.
Explanation: Cushing’s syndrome is caused by excess cortisol, leading to characteristic
symptoms such as moon face, buffalo hump (fat pad at the upper back), and truncal obesity.
These are hallmark physical findings due to fat redistribution.
A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the
status report provided by the nurse who is leaving for lunch, which client should be checked first
by the charge nurse? The client
A. with a history of asthma who is receiving oxygen at 2 liters per minute.
B. postoperative from an appendectomy with stable vital signs.
C. with chest pain and new-onset arrhythmias.
D. with diabetes mellitus receiving insulin via infusion pump.
Correct Answer: C. with chest pain and new-onset arrhythmias.
Explanation: Chest pain with new-onset arrhythmias indicates a potentially life-threatening
condition, such as acute coronary syndrome or cardiac instability, requiring immediate
assessment and intervention.
, An outcome for treatment of peripheral vascular disease is, “The client will have decreased
venous congestion.” What client behavior would indicate to the nurse that this outcome has been
met?
A. The client elevates the legs when sitting.
B. The client avoids tight clothing on the legs.
C. The client walks daily for 30 minutes.
D. The client applies moisturizer to dry skin.
Correct Answer: A. The client elevates the legs when sitting.
Explanation: Elevating the legs promotes venous return and reduces venous congestion,
directly addressing the outcome. Other options may support general vascular health but do not
specifically target venous congestion.
The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are
removed. Which assessment parameter is most critical for the nurse to monitor following the
procedure?
A. Blood pressure.
B. Serum sodium levels.
C. Abdominal girth.
D. Respiratory rate.
Correct Answer: A. Blood pressure.
Explanation: Removing a large volume of fluid (3 liters) during paracentesis can cause a rapid
shift in intravascular volume, potentially leading to hypotension. Monitoring blood pressure is
critical to detect and manage this complication.
The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal
disease (ESRD). The client asks the nurse to bring the medication later. The nurse should
describe which action of RenaGel as an explanation for taking it with meals?
A. It reduces nausea associated with meals.
B. It binds phosphates in the gastrointestinal tract.
C. It enhances absorption of dietary calcium.
D. It prevents gastric irritation from other medications.
Correct Answer: B. It binds phosphates in the gastrointestinal tract.
Explanation: Sevelamer is a phosphate binder used in ESRD to reduce serum phosphate
levels by binding dietary phosphates in the gut, preventing their absorption. Taking it with meals
maximizes its effectiveness.
