HESI RN CRITICAL CARE ACTUAL EXAM V1 COMPLETE 500
QUESTIONS WITH CORRECT DETAILED ANSWERS LATEST
UPDATE THIS YEAR - JUST RELEASED
Your answers
Term 1 of 124
Following major abdominal surgery, a male client's arterial blood gas
analysis reveals Pa02
95mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula
at 4 liters/minute and is
reluctant to move in bed or deep breathe. Based on this information,
what action should the nurse
implement at this time?
A. Encourage the client to breathe slower.
B. Notify the healthcare provider of the crisis blood gas values.
C. Encourage the use of an incentive spirometer.
D. Increase the oxygen flow to 6 liters/minute.
Give this one a try later!
,C. Young adult female presents with periorbital ecchymosis on right side, 3 cm
laceration on
left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is
abusive.
Rationale: Proper documentation of abuse as reported by the victim is crucial, and (D)
is specific and gives
an accurate depiction of the events without documentation of judgmental inferences.
(A, B, and
C) l a c k specificity and important details r lated to the event
C . Encourage the use of an incentive spirometer.
RATIONALE:
The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation
(PaC02 > 45). The
client needs to be encouraged in activities that increase the depth of breathing
(e. g., use of the
incentive spirometer) (B). (A) will only increase an already adequate Pa02. These
are not crisis
blood gas findings (C). (D) will only worsen the hypoventilation
A. Obtain the permission of the custodial parent for the surgery.
RATIONALE:
The client is a minor and cannot legally sign his own consent unless he is an
emancipated minor,
so the consent should be obtained from the guardian for this client, which is the
custodial parent
(B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the
child has
been adopted by the stepparent (C). The non-custodial parent does not need to co-
sign this form
(D).
A. Implements health programs for construction workers.
Rationale: Implementing health programs for construction workers (B) is an example of
a competent
performance criterion in management, which includes monitoring of the quality and
effectiveness of vendor services. (A) is an example of an expert performance criterion
for case
management. (C and D) are examples of a proficient performance criteria for
management.
Don't know?
,Term 2 of 124
The nurse is developing a teaching plan for an adolescent with a
Milwaukee brace. Which
instruction should the nurse include?
A. Wear the brace over a T-shirt 23 hours per day.
B. Dress with the brace over regular clothing.
C. Shower with the brace directly against the skin.
D. Remove the brace just before going to bed.
Give this one a try later!
C. Drinks 240 mL of fluid five times during the shift
RATIONALE:
The nurse should evaluate the client's outcome by observing the client's performance
of each
expected behavior, so drinking 240 mL of fluid five or six times during the shift (D)
indicates a
fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during
the
designated period. (A) uses the term "adequate," which is not quantified. (B) is not the
objective,
which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific
fluid
intake.
A. Wear the brace over a T-shirt 23 hours per day.
RATIONALE:
Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent
females. Early
treatment uses a Milwaukee brace that places pressure against the lateral spinal
curvature, under
the neck, and against the iliac crest, so it should be worn for 23 hours per day
over a T-shirt (D)
which reduces friction and chafing of the skin. (A, B, and C) reduce the
effectiveness of the
brace.
, C. History of inflammatory bowel disorders.
RATIONALE:
Enemas should be avoided or administered with extreme caution to clients with
inflammatory
bowel disorders, so obtaining this historical information has the highest priority (A). (B
and C)
also provide valuable information, but are not of the same priority as (A). (D) is not
necessary
prior to enema administration.
Assign the client to a negative air-flow room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client
should be
assigned to a negative pressure air-flow room (D). Although (A and C) should be
implemented
for clients in isolation with contact precautions, it is most important that air flow from
the room
is minimized when the client has TB. (B) should be implemented when the client leaves
the
isolation environment.
Don't know?
Term 3 of 124
An 80-year-old client is given morphine sulphate for postoperative pain.
Which concomitant
medication should the nurse question that poses a potential
development of urinary retention in
this geriatric client?
A. Antacids.
B. Tricyclic antidepressants.
C. Nonsteroidal anti-inflammatory agents.
D. Insulin.
QUESTIONS WITH CORRECT DETAILED ANSWERS LATEST
UPDATE THIS YEAR - JUST RELEASED
Your answers
Term 1 of 124
Following major abdominal surgery, a male client's arterial blood gas
analysis reveals Pa02
95mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula
at 4 liters/minute and is
reluctant to move in bed or deep breathe. Based on this information,
what action should the nurse
implement at this time?
A. Encourage the client to breathe slower.
B. Notify the healthcare provider of the crisis blood gas values.
C. Encourage the use of an incentive spirometer.
D. Increase the oxygen flow to 6 liters/minute.
Give this one a try later!
,C. Young adult female presents with periorbital ecchymosis on right side, 3 cm
laceration on
left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is
abusive.
Rationale: Proper documentation of abuse as reported by the victim is crucial, and (D)
is specific and gives
an accurate depiction of the events without documentation of judgmental inferences.
(A, B, and
C) l a c k specificity and important details r lated to the event
C . Encourage the use of an incentive spirometer.
RATIONALE:
The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation
(PaC02 > 45). The
client needs to be encouraged in activities that increase the depth of breathing
(e. g., use of the
incentive spirometer) (B). (A) will only increase an already adequate Pa02. These
are not crisis
blood gas findings (C). (D) will only worsen the hypoventilation
A. Obtain the permission of the custodial parent for the surgery.
RATIONALE:
The client is a minor and cannot legally sign his own consent unless he is an
emancipated minor,
so the consent should be obtained from the guardian for this client, which is the
custodial parent
(B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the
child has
been adopted by the stepparent (C). The non-custodial parent does not need to co-
sign this form
(D).
A. Implements health programs for construction workers.
Rationale: Implementing health programs for construction workers (B) is an example of
a competent
performance criterion in management, which includes monitoring of the quality and
effectiveness of vendor services. (A) is an example of an expert performance criterion
for case
management. (C and D) are examples of a proficient performance criteria for
management.
Don't know?
,Term 2 of 124
The nurse is developing a teaching plan for an adolescent with a
Milwaukee brace. Which
instruction should the nurse include?
A. Wear the brace over a T-shirt 23 hours per day.
B. Dress with the brace over regular clothing.
C. Shower with the brace directly against the skin.
D. Remove the brace just before going to bed.
Give this one a try later!
C. Drinks 240 mL of fluid five times during the shift
RATIONALE:
The nurse should evaluate the client's outcome by observing the client's performance
of each
expected behavior, so drinking 240 mL of fluid five or six times during the shift (D)
indicates a
fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during
the
designated period. (A) uses the term "adequate," which is not quantified. (B) is not the
objective,
which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific
fluid
intake.
A. Wear the brace over a T-shirt 23 hours per day.
RATIONALE:
Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent
females. Early
treatment uses a Milwaukee brace that places pressure against the lateral spinal
curvature, under
the neck, and against the iliac crest, so it should be worn for 23 hours per day
over a T-shirt (D)
which reduces friction and chafing of the skin. (A, B, and C) reduce the
effectiveness of the
brace.
, C. History of inflammatory bowel disorders.
RATIONALE:
Enemas should be avoided or administered with extreme caution to clients with
inflammatory
bowel disorders, so obtaining this historical information has the highest priority (A). (B
and C)
also provide valuable information, but are not of the same priority as (A). (D) is not
necessary
prior to enema administration.
Assign the client to a negative air-flow room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client
should be
assigned to a negative pressure air-flow room (D). Although (A and C) should be
implemented
for clients in isolation with contact precautions, it is most important that air flow from
the room
is minimized when the client has TB. (B) should be implemented when the client leaves
the
isolation environment.
Don't know?
Term 3 of 124
An 80-year-old client is given morphine sulphate for postoperative pain.
Which concomitant
medication should the nurse question that poses a potential
development of urinary retention in
this geriatric client?
A. Antacids.
B. Tricyclic antidepressants.
C. Nonsteroidal anti-inflammatory agents.
D. Insulin.
