CRITICAL CARE HESI PRACTICE Q ESSENTIAL
STUDY QUESTIONS AND ANSWERS
◉ A client who experiences multiple traumatic injuries begins to
ooze blood from an injection site. Which additional finding should
the nurse identify that supports an early indication of disseminated
intravascular coagulation (DIC)?
a. Negative D-dimer test.
b. Edema of the extremities.
c. Shorter clotting times.
d. Bleeding from oral mucosa.
Answer: Edema of the extremities.
◉ The vital signs for a client with heart failure, who is admitted to
the intensive care unit are temperature, 98.6F, heart rate 125 bpm,
respirations 22 bpm, and blood pressure 140/50 mmHg. The nurse
determines the client's central venous pressure (CVP) and
pulmonary artery wedge pressure (PAWP) are elevated. Which
intervention should the nurse implement?
a. Administer furosemide 40 mg IV.
b. Encourage a liberal PO fluid intake.
c. Titrate IV dopamine at 8 mcg/kg/minute.
d. Initiate IV bolus of 500 mL normal saline.
,Answer: Administer furosemide 40mg IV.
◉ A client with diabetes is admitted to the intensive care unit with
decreased level of consciousness, nausea, vomiting, and fruity
breath. Based on these assessment findings, which action should the
nurse take?
a. Assess serum glucose level.
b. Review the client's serum potassium level.
c. Evaluate the client's 24 hour intake and output.
d. Give an IV bolus of 50% glucose.
Answer: a. Assess serum glucose level.
◉ A client arrives in the emergency department complaining of
chest pain. Which description should prompt the nurse to suspect
that the chest pain is originating from the myocardium?
a. Produces a chest heaviness along with left arm pain.
b. Worsens while at rest in Fowler's position.
c. Increases when any slow, deep breath is taken.
d. Creates a throbbing which is superficial in nature.
Answer: Produces a chest heaviness along with left arm pain.
◉ An adult client is admitted to the emergency department with
sanguineous drainage from a scalp wound and coming from both
, ears following falling from a tree while trimming it. Which action is
most important for the nurse to take?
a. Provide sterile wound care and sterile non stick dressing.
b. Asses for periorbital swelling and ecchymosis.
c. Determine client's response on the Glasgow coma scale.
d. Ask the family if the client has an advanced directive.
Answer: b. Asses for periorbital swelling and ecchymosis.
◉ A client requiring an emergency intubation is placed on a
mechanical ventilator. The endotracheal tube (ETT) is secured at 23
cm. Which assessment should the nurse communicate immediately
to the healthcare provider?
a. Blood-tinged mucous with suctioning.
b. Spontaneous respiratory effort
c. Diminished left lung sounds.
d. Bilateral expiratory wheezes.
Answer: Diminished left lung sounds.
◉ An adult who fell 20 feet from a tree is admitted to the
intermediate intensive care unit with a fractured femur. When the
cardiac monitor alarms, the nurse finds the client has no palpable
carotid pulse and no spontaneous respiration, however, the cardiac
monitor displays a sinus rhythm. Which intervention should the
nurse implement?
STUDY QUESTIONS AND ANSWERS
◉ A client who experiences multiple traumatic injuries begins to
ooze blood from an injection site. Which additional finding should
the nurse identify that supports an early indication of disseminated
intravascular coagulation (DIC)?
a. Negative D-dimer test.
b. Edema of the extremities.
c. Shorter clotting times.
d. Bleeding from oral mucosa.
Answer: Edema of the extremities.
◉ The vital signs for a client with heart failure, who is admitted to
the intensive care unit are temperature, 98.6F, heart rate 125 bpm,
respirations 22 bpm, and blood pressure 140/50 mmHg. The nurse
determines the client's central venous pressure (CVP) and
pulmonary artery wedge pressure (PAWP) are elevated. Which
intervention should the nurse implement?
a. Administer furosemide 40 mg IV.
b. Encourage a liberal PO fluid intake.
c. Titrate IV dopamine at 8 mcg/kg/minute.
d. Initiate IV bolus of 500 mL normal saline.
,Answer: Administer furosemide 40mg IV.
◉ A client with diabetes is admitted to the intensive care unit with
decreased level of consciousness, nausea, vomiting, and fruity
breath. Based on these assessment findings, which action should the
nurse take?
a. Assess serum glucose level.
b. Review the client's serum potassium level.
c. Evaluate the client's 24 hour intake and output.
d. Give an IV bolus of 50% glucose.
Answer: a. Assess serum glucose level.
◉ A client arrives in the emergency department complaining of
chest pain. Which description should prompt the nurse to suspect
that the chest pain is originating from the myocardium?
a. Produces a chest heaviness along with left arm pain.
b. Worsens while at rest in Fowler's position.
c. Increases when any slow, deep breath is taken.
d. Creates a throbbing which is superficial in nature.
Answer: Produces a chest heaviness along with left arm pain.
◉ An adult client is admitted to the emergency department with
sanguineous drainage from a scalp wound and coming from both
, ears following falling from a tree while trimming it. Which action is
most important for the nurse to take?
a. Provide sterile wound care and sterile non stick dressing.
b. Asses for periorbital swelling and ecchymosis.
c. Determine client's response on the Glasgow coma scale.
d. Ask the family if the client has an advanced directive.
Answer: b. Asses for periorbital swelling and ecchymosis.
◉ A client requiring an emergency intubation is placed on a
mechanical ventilator. The endotracheal tube (ETT) is secured at 23
cm. Which assessment should the nurse communicate immediately
to the healthcare provider?
a. Blood-tinged mucous with suctioning.
b. Spontaneous respiratory effort
c. Diminished left lung sounds.
d. Bilateral expiratory wheezes.
Answer: Diminished left lung sounds.
◉ An adult who fell 20 feet from a tree is admitted to the
intermediate intensive care unit with a fractured femur. When the
cardiac monitor alarms, the nurse finds the client has no palpable
carotid pulse and no spontaneous respiration, however, the cardiac
monitor displays a sinus rhythm. Which intervention should the
nurse implement?
