Critical Care Exit Hesi
1. The nurse cares for a client with a cuffed tracheostomy tube. Before per- forming
oral care, the nurse notes that the client's tracheostomy cuff is in- flated. 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.: 1
2. A young adult brings a friend to 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: 2
3. The client tells the clinic nurse that the client is thinking about using nico- tine
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?": 3
4. The nurse cares for the client 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.: 4
5. A pregnant woman receives an 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: 3
6. A nursing order, "Increase fluid intake" is written for a client diagnosed with
dehydration. Which finding BEST indicates improving fluid status?
, Critical Care Exit Hesi
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.: 1
7. The nurse prepares to 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.: 2
8. The home care nurse visits a 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.": 3
9. the nurse cares for a client 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.": 1
10. The nurse on the maternity unit must accept a transfer client from a
medical/surgical unit. The nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client receiving daily external radiation therapy treatments for breast
cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days.: 1
11. The nurse in the outclient surgery unit prepares a 4-year-old child for
surgery. It is MOST important for the nurse to make which of these state-
ments?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done.: 4
12. The nurse cares for a client diagnosed with Alzheimer's disease. The client is
confused and incontinent of urine. What is the MOST important action for
1. The nurse cares for a client with a cuffed tracheostomy tube. Before per- forming
oral care, the nurse notes that the client's tracheostomy cuff is in- flated. 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.: 1
2. A young adult brings a friend to 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: 2
3. The client tells the clinic nurse that the client is thinking about using nico- tine
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?": 3
4. The nurse cares for the client 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.: 4
5. A pregnant woman receives an 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: 3
6. A nursing order, "Increase fluid intake" is written for a client diagnosed with
dehydration. Which finding BEST indicates improving fluid status?
, Critical Care Exit Hesi
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.: 1
7. The nurse prepares to 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.: 2
8. The home care nurse visits a 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.": 3
9. the nurse cares for a client 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.": 1
10. The nurse on the maternity unit must accept a transfer client from a
medical/surgical unit. The nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client receiving daily external radiation therapy treatments for breast
cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days.: 1
11. The nurse in the outclient surgery unit prepares a 4-year-old child for
surgery. It is MOST important for the nurse to make which of these state-
ments?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done.: 4
12. The nurse cares for a client diagnosed with Alzheimer's disease. The client is
confused and incontinent of urine. What is the MOST important action for
