HESI Critical Care Exam solved questions and verified answers.

HESI Critical Care Exam solved questions
and verified answers.

.Prior to a cardiac catheterization, which activity should the nurse have the client practice?
j j j j j j j j j j j j j




A. Remain motionless for 5 minutes.
j j j j j




B. Flexing hips and knees bilaterally.
j j j j j




C. Valsalva's maneuver and coughing.
j j j j




D. Talking while walking on a treadmill - ANSW -C. Valsalva's maneuver and coughing.
j j j j j j j j j j j j j




RATIONALE:

Before the cardiac catheterization, the client should practice techniques (e.g., Valsalva's
j j j j j j j j j j




maneuver, coughing, deep breathing) that will be used during the procedure (B). The client
j j j j j j j j j j j j j




should keep the leg straight, not (A), for the prescribed number of hours post cardiac
j j j j j j j j j j j j j j




catheterization to prevent bleeding from the arterial access site. (C) is not used in this procedure. j j j j j j j j j j j j j j j




The client may be asked to change position during the procedure, so (D) is not necessary.
j j j j j j j j j j j j j j j




1.A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most
j j j j j j j j j j j j j j j j




important for the nurse to implement? j j j j j




A. Fit the client with a respirator mask.
j j j j j j j




B. Assign the client to a negative air-flow room.
j j j j j j j j




C. Don a clean gown for client care.
j j j j j j j




D. Place an isolation cart in the hallway - ANSW -Assign the client to a negative air-flow room
j j j j j j j j j j j j j j j j j




RATIONALE:

Active tuberculosis requires implementation of airborne precautions, so the client should be
j j j j j j j j j j j




assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented
j j j j j j j j j j j j j j




for clients in isolation with contact precautions, it is most important that air flow from the room
j j j j j j j j j j j j j j j j




is minimized when the client has TB. (B) should be implemented when the client leaves the
j j j j j j j j j j j j j j j




isolation environment. j




2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse
j j j j j j j j j j j j j j

,determines the client's apical pulse is 65 beats per minute. What action should the nurse
j j j j j j j j j j j j j j




implement

next?

A. Measure the blood pressure.
j j j j




B. Reassess the apical pulse.
j j j j




C. Notify the healthcare provider.
j j j j




D. Administer the medication. - ANSW -Administer the medication
j j j j j j j j




RATIONALE:

Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate,
j j j j j j j j j j j j j j j




so the medication should be administered (C) because the client's apical pulse is greater than 60.
j j j j j j j j j j j j j j j




(A, B, and D) are not indicated at this time.
j j j j j j j j j




3.The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent
j j j j j j j j j j j j j j j j




with which interpretation?
j j




A. Hypothyroidism.
j




B. Thyroid cyst.
j j




C. Thyroid cancer.
j j




D. Hyperthyroidism - ANSW -Hyperthyroidism
j j j j




Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a j j j j j j j j j j j j j j j j




bruit may be auscultated over the goiter due to an increase in glandular vascularity which
j j j j j j j j j j j j j j




increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).
j j j j j j j j j j j j j j j j




A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a
j j j j j j j j j j j j j j j j




fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture.
j j j j j j j j j j j j




Which action should be implemented to obtain a valid informed consent?
j j j j j j j j j j




A. Obtain the permission of the custodial parent for the surgery.
j j j j j j j j j j




B. Notify the non-custodial parent to also sign a consent form.
j j j j j j j j j j




C. Instruct the client sign the consent before giving medications.
j j j j j j j j j




D. Obtain the signature of the client's stepfather for the surgery. - ANSW -A. Obtain the permission of the
j j j j j j j j j j j j j j j j j j



custodial parent for the surgery.
j j j j j




RATIONALE:

,The client is a minor and cannot legally sign his own consent unless he is an emancipated minor,
j j j j j j j j j j j j j j j j j




so the consent should be obtained from the guardian for this client, which is the custodial parent
j j j j j j j j j j j j j j j j




(B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has
j j j j j j j j j j j j j j j j j j j j




been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form
j j j j j j j j j j j j j j j




(D).

A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which
j j j j j j j j j j j j




nurse should be assigned to care for this client?
j j j j j j j j




A. The nurse who is caring for another client receiving intracavitary radiation.
j j j j j j j j j j j




B. A nurse with Marfan's syndrome who is postmenopausal.
j j j j j j j j




C. A nurse with oncology experience who may be pregnant.
j j j j j j j j j




D. The nurse who is caring for another client who has Clostridium difficile. - ANSW -B. A nurse with Marfan's
j j j j j j j j j j j j j j j j j j j



syndrome who is postmenopausal.
j j j j




RATIONALE:

A client receiving intracavity radiation poses a radiation hazard as long as the intracavity
j j j j j j j j j j j j j




radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's
j j j j j j j j j j j j j j j j j




syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments
j j j j j j j j j j j j




and skeletal structures. The goal is to limit any one staff member's exposure to the calculated
j j j j j j j j j j j j j j j




time span based on the half-life of radium, such as the number of minutes at the bedside per day,
j j j j j j j j j j j j j j j j j j




so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible
j j j j j j j j j j j j j j j j j




effect on the fetus. A radiation exposure decreases the immune response in the client who should
j j j j j j j j j j j j j j j




not be exposed to the potential inadvertent transmission of an infectious organism (D).
j j j j j j j j j j j j




A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and
j j j j j j j j j j j j j j j j



ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for
j j j j j j j j j j j j j j j j j



additional manifestations of a basilar skull fracture. What
j j j j j j j j




assessment finding would be consistent with a basilar skull fracture? j j j j j j j j j




A. Hematemesis and abdominal distention.
j j j j




B. Asymmetry of the face and eye movements.
j j j j j j j




C. Rhinorrhoea or otorrhoea with Halo sign.
j j j j j j




D. Abnormal position and movement of the arm. - ANSW -Rhinorrhoea or otorrhoea with Halo sign.
j j j j j j j j j j j j j j j




RATIONALE:

, Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the
j j j j j j j j j j j j




mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible
j j j j j j j j j j j j j j j j




meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is
j j j j j j j j j j j j j j j j j j




consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm
j j j j j j j j j j j j j




fractures. (C) occurs with blunt abdominal injuries. j j j j j j




A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her
j j j j j j j j j j j j j j j j



daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the
j j j j j j j j j j j j j j j j j j j j



table for her deceased husband. What nursing problem best describes this problem?
j j j j j j j j j j j j




A. Confusion related to recent death of loved one.
j j j j j j j j




B. Unresolved anger related to death of husband.
j j j j j j j




C. Delayed grief reaction related to death of husband.
j j j j j j j j




D. Denial related to the loss of a loved one - ANSW -D. Denial related to the loss of a loved one.
j j j j j j j j j j j j j j j j j j j j j




RATIONALE:

Based on the data provided, (C) is the best nursing diagnosis. This client is exhibiting symptoms
j j j j j j j j j j j j j j j




of anxiety and the pain is too great for her to acknowledge, so she is denying the situation.
j j j j j j j j j j j j j j j j j




Although she may seem confused (A), she is actually trying to deal with the pain through the
j j j j j j j j j j j j j j j j




defense mechanism of denial. (B) occurs after one year or longer following the loss. The client's
j j j j j j j j j j j j j j j




husband died one month ago. (D) and depression are often related, and depression is sometimes
j j j j j j j j j j j j j j




described as unexpressed anger. However, this client has not acknowledged her loss (denial) and
j j j j j j j j j j j j j




the anger is not yet realized.
j j j j j




A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks
j j j j j j j j j j j j j j




the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should
j j j j j j j j j j j j j j j j j j j




the nurse respond?
j j




A. "To protect you because you can get an infection very easily."
j j j j j j j j j j j




B. "Your condition could be spread to staff and other clients in the hospital."
j j j j j j j j j j j j j




C. "There are many forms of bacteria and germs in the hospital."
j j j j j j j j j j j




D. "After taking medication for 24 hours a gown and mask won't be needed." - ANSW -A. "To protect you
j j j j j j j j j j j j j j j j j j j



because you can get an infection very easily."
j j j j j j j j




RATIONALE:

Reverse isolation precaution implement measures to protect the client from exposure to
j j j j j j j j j j j