Critical Care HESI - set 2 with 100%
correct answers 2025
The nurse calculating fluid resuscitation for young male who was burned in a bloody
accident at 12 noon and is seen in the emergency center at 2 pm. The healthcare
provider determines that the client has burns over 30% of his body, mainly on the arms
and chest. Using the Parkland formula for fluid resuscitation, the client is to receive
7000 mL of fluid in 24 hours. Which goal should the nurse established for this clients
plan of care - Correct AnswerBy 8 pm, the client will have received 3500 mL of fluid
When caring for a client on a ventilator, which finding provides the greatest indication
that the client has an open airway? - Correct AnswerBilateral breath sounds can be
auscultating
The nurse performs a neurological check at the beginning of the shift on a client who
was admitted to the hospital with a subarachnoid brain attack (stroke). The client's
Glasgow coma scale (GCS) is 9. Which information is most important for the nurse to
determine - Correct AnswerThe client's previous GCS score
An adult female with a history of type 1 diabetes mellitus has been vomitting for the past
48 hours and is admitted to the intensive care unit with diabetic ketoacidosis (DKA).
Which assessment finding warrants immediate intervention by the nurse? - Correct
Answerexcessive thirst
A client is admitted to the intensive care unit (ICU) after a colon resection with a
formation of the loop colostomy. The nurse determines that the clients abdominal
dressing is clean and dry. Vital signs are heart rate is 130, temperature 101, blood
pressure 88/65 mmHg, and urine output 10 mL/hour. Which interventions should the
nurse implement? - Correct AnswerGive a 500 mL IV fluid bolus challenge
A client is admitted with a syncopal episodes related to a third-degree heart block. After
the placement of a transcutaneous pacemaker, the nurse observes several episodes
the pacemaker failure to sense. What action should the nurse take? - Correct
AnswerIncrease the sensitivity
A client is receiving cardiopulmonary resuscitation. After systole is confirmed in two
leads and sending the transcutaneous pacemaker, which intravenous medication
should be administered - Correct Answerepinephrine (adrenaline)
A client has a chest tube connected to a closed water-seal drainage system with
suction. What equipment should the nurse always have available at the client's bedside
- Correct AnswerOcculsive dressing (just in case tube comes out)
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL DS W at
6mL/hour. How many mcg per min of nitroglycerin is infusing? - Correct Answer20
, Bretylium 1mg/minute via infusion is prescribed for s client and ventricular tachycardia.
The available solution 500 mL DSW contains bretylium 1 gram. The nurse should
program the infusion time to deliver how many mL per hour - Correct Answer30
A client arrives in the emergency department complaining in pain. Which description of
pain should prompt the nurse to suspect that it originated in the myocardium? - Correct
AnswerProduces chest heaviness along with left arm pain
Four days ago a chest tube was inserted into the second intercostal space of a client
who has a pneumothorax. Today the nurse notes that there is no fluctuation in the
water-seal chamber of the Pleuravac. Which intervention would be most appropriate for
the nurse to implement? - Correct AnswerAssess the client's breath sounds on the
AFFECTED lung
In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize that which intervention is essential - Correct AnswerEncourage
the client to breathe deeply and cough at frequent intervals
A postoperative client is admitted to the intensive care unit with an inflated pressure
infuser containing a solution of heparin 2 unit/mL attached to a intra material (IA)
cannula. Which finding indicates that the heparin infusion has achieved its therapeutic
use - Correct AnswerIntra-arterial cannula REMAINS patent
The nurse suspects that a client with a central venous catheter in the left subclavian
vein experiencing an embolism. What signs and symptoms are most indicative of this
condition? - Correct AnswerAnxiety, confusion, lightheadedness and loss of
conciousness
A female client has been in systole for twenty minutes. She is intubated and epinephrine
(adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in
the rhythm. Which intervention should the nurse implement? - Correct AnswerBring
members of the family to a private area to discuss the desire to continue life support
efforts.
The nurse is evaluating a client's central venous pressure (CVP) reading that are
trending upwards,. What nursing diagnoses is supported by the pathophysiological
mechanism most likely causing this increase. - Correct AnswerImpaired cardiac output
The high-pressure alarm on a mechanical ventilator is sounding. Which intervention
should the nurse implement immediately? - Correct AnswerAuscultate bilaterally for
breath sounds and conform endotracheal suctioning
A client with a history go a vasovagal attacks resulting in Brady-dysrythmias. Which
instruction is most important in the teaching plan - Correct AnswerUse stool softeners
regularly
correct answers 2025
The nurse calculating fluid resuscitation for young male who was burned in a bloody
accident at 12 noon and is seen in the emergency center at 2 pm. The healthcare
provider determines that the client has burns over 30% of his body, mainly on the arms
and chest. Using the Parkland formula for fluid resuscitation, the client is to receive
7000 mL of fluid in 24 hours. Which goal should the nurse established for this clients
plan of care - Correct AnswerBy 8 pm, the client will have received 3500 mL of fluid
When caring for a client on a ventilator, which finding provides the greatest indication
that the client has an open airway? - Correct AnswerBilateral breath sounds can be
auscultating
The nurse performs a neurological check at the beginning of the shift on a client who
was admitted to the hospital with a subarachnoid brain attack (stroke). The client's
Glasgow coma scale (GCS) is 9. Which information is most important for the nurse to
determine - Correct AnswerThe client's previous GCS score
An adult female with a history of type 1 diabetes mellitus has been vomitting for the past
48 hours and is admitted to the intensive care unit with diabetic ketoacidosis (DKA).
Which assessment finding warrants immediate intervention by the nurse? - Correct
Answerexcessive thirst
A client is admitted to the intensive care unit (ICU) after a colon resection with a
formation of the loop colostomy. The nurse determines that the clients abdominal
dressing is clean and dry. Vital signs are heart rate is 130, temperature 101, blood
pressure 88/65 mmHg, and urine output 10 mL/hour. Which interventions should the
nurse implement? - Correct AnswerGive a 500 mL IV fluid bolus challenge
A client is admitted with a syncopal episodes related to a third-degree heart block. After
the placement of a transcutaneous pacemaker, the nurse observes several episodes
the pacemaker failure to sense. What action should the nurse take? - Correct
AnswerIncrease the sensitivity
A client is receiving cardiopulmonary resuscitation. After systole is confirmed in two
leads and sending the transcutaneous pacemaker, which intravenous medication
should be administered - Correct Answerepinephrine (adrenaline)
A client has a chest tube connected to a closed water-seal drainage system with
suction. What equipment should the nurse always have available at the client's bedside
- Correct AnswerOcculsive dressing (just in case tube comes out)
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL DS W at
6mL/hour. How many mcg per min of nitroglycerin is infusing? - Correct Answer20
, Bretylium 1mg/minute via infusion is prescribed for s client and ventricular tachycardia.
The available solution 500 mL DSW contains bretylium 1 gram. The nurse should
program the infusion time to deliver how many mL per hour - Correct Answer30
A client arrives in the emergency department complaining in pain. Which description of
pain should prompt the nurse to suspect that it originated in the myocardium? - Correct
AnswerProduces chest heaviness along with left arm pain
Four days ago a chest tube was inserted into the second intercostal space of a client
who has a pneumothorax. Today the nurse notes that there is no fluctuation in the
water-seal chamber of the Pleuravac. Which intervention would be most appropriate for
the nurse to implement? - Correct AnswerAssess the client's breath sounds on the
AFFECTED lung
In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize that which intervention is essential - Correct AnswerEncourage
the client to breathe deeply and cough at frequent intervals
A postoperative client is admitted to the intensive care unit with an inflated pressure
infuser containing a solution of heparin 2 unit/mL attached to a intra material (IA)
cannula. Which finding indicates that the heparin infusion has achieved its therapeutic
use - Correct AnswerIntra-arterial cannula REMAINS patent
The nurse suspects that a client with a central venous catheter in the left subclavian
vein experiencing an embolism. What signs and symptoms are most indicative of this
condition? - Correct AnswerAnxiety, confusion, lightheadedness and loss of
conciousness
A female client has been in systole for twenty minutes. She is intubated and epinephrine
(adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in
the rhythm. Which intervention should the nurse implement? - Correct AnswerBring
members of the family to a private area to discuss the desire to continue life support
efforts.
The nurse is evaluating a client's central venous pressure (CVP) reading that are
trending upwards,. What nursing diagnoses is supported by the pathophysiological
mechanism most likely causing this increase. - Correct AnswerImpaired cardiac output
The high-pressure alarm on a mechanical ventilator is sounding. Which intervention
should the nurse implement immediately? - Correct AnswerAuscultate bilaterally for
breath sounds and conform endotracheal suctioning
A client with a history go a vasovagal attacks resulting in Brady-dysrythmias. Which
instruction is most important in the teaching plan - Correct AnswerUse stool softeners
regularly
