HESI Critical Care Exam :Questions and Verified Answers
.Prior to a cardiac catheterization, which activity should the nurse have the client practice?
A. Remain motionless for 5 minutes.
B. Flexing hips and knees bilaterally.
C. Valsalva's maneuver and coughing.
D. Talking while walking on a treadmill - ansC. Valsalva's maneuver and coughing.
RATIONALE:
Before the cardiac catheterization, the client should practice techniques (e.g., Valsalva's
maneuver, coughing, deep breathing) that will be used during the procedure (B). The client
should keep the leg straight, not (A), for the prescribed number of hours post cardiac
catheterization to prevent bleeding from the arterial access site. (C) is not used in this procedure.
The client may be asked to change position during the procedure, so (D) is not necessary.
1.A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most
important for the nurse to implement?
A. Fit the client with a respirator mask.
B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway - ansAssign 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.
,2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse
determines the client's apical pulse is 65 beats per minute. What action should the nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. - ansAdminister the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate,
so the medication should be administered (C) because the client's apical pulse is greater than 60.
(A, B, and D) are not indicated at this time.
3.The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism - ansHyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in glandular vascularity which
increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a
fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture.
Which action should be implemented to obtain a valid informed consent?
A. Obtain the permission of the custodial parent for the surgery.
,B. Notify the non-custodial parent to also sign a consent form.
C. Instruct the client sign the consent before giving medications.
D. Obtain the signature of the client's stepfather for the surgery. - ansA. 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 56-year-old female client is receiving intracavitary radiation via a radium implant. Which
nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary radiation.
B. A nurse with Marfan's syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium difficile. - ansB. A nurse with Marfan's
syndrome who is postmenopausal.
RATIONALE:
A client receiving intracavity radiation poses a radiation hazard as long as the intracavity
radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's
syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments
and skeletal structures. The goal is to limit any one staff member's exposure to the calculated
time span based on the half-life of radium, such as the number of minutes at the bedside per day,
so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible
effect on the fetus. A radiation exposure decreases the immune response in the client who should
not be exposed to the potential inadvertent transmission of an infectious organism (D).
, A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and
ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for
additional manifestations of a basilar skull fracture. What
assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ansRhinorrhoea or otorrhoea with Halo sign.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is
consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm
fractures. (C) occurs with blunt abdominal injuries.
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter
tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her
deceased husband. What nursing problem best describes this problem?
A. Confusion related to recent death of loved one.
B. Unresolved anger related to death of husband.
C. Delayed grief reaction related to death of husband.
D. Denial related to the loss of a loved one - ansD. Denial related to the loss of a loved one.
RATIONALE:
Based on the data provided, (C) is the best nursing diagnosis. This client is exhibiting symptoms
of anxiety and the pain is too great for her to acknowledge, so she is denying the situation.
Although she may seem confused (A), she is actually trying to deal with the pain through the
defense mechanism of denial. (B) occurs after one year or longer following the loss. The client's
.Prior to a cardiac catheterization, which activity should the nurse have the client practice?
A. Remain motionless for 5 minutes.
B. Flexing hips and knees bilaterally.
C. Valsalva's maneuver and coughing.
D. Talking while walking on a treadmill - ansC. Valsalva's maneuver and coughing.
RATIONALE:
Before the cardiac catheterization, the client should practice techniques (e.g., Valsalva's
maneuver, coughing, deep breathing) that will be used during the procedure (B). The client
should keep the leg straight, not (A), for the prescribed number of hours post cardiac
catheterization to prevent bleeding from the arterial access site. (C) is not used in this procedure.
The client may be asked to change position during the procedure, so (D) is not necessary.
1.A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most
important for the nurse to implement?
A. Fit the client with a respirator mask.
B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway - ansAssign 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.
,2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse
determines the client's apical pulse is 65 beats per minute. What action should the nurse
implement
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication. - ansAdminister the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate,
so the medication should be administered (C) because the client's apical pulse is greater than 60.
(A, B, and D) are not indicated at this time.
3.The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid cancer.
D. Hyperthyroidism - ansHyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a
bruit may be auscultated over the goiter due to an increase in glandular vascularity which
increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a
fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture.
Which action should be implemented to obtain a valid informed consent?
A. Obtain the permission of the custodial parent for the surgery.
,B. Notify the non-custodial parent to also sign a consent form.
C. Instruct the client sign the consent before giving medications.
D. Obtain the signature of the client's stepfather for the surgery. - ansA. 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 56-year-old female client is receiving intracavitary radiation via a radium implant. Which
nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary radiation.
B. A nurse with Marfan's syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium difficile. - ansB. A nurse with Marfan's
syndrome who is postmenopausal.
RATIONALE:
A client receiving intracavity radiation poses a radiation hazard as long as the intracavity
radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's
syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments
and skeletal structures. The goal is to limit any one staff member's exposure to the calculated
time span based on the half-life of radium, such as the number of minutes at the bedside per day,
so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible
effect on the fetus. A radiation exposure decreases the immune response in the client who should
not be exposed to the potential inadvertent transmission of an infectious organism (D).
, A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and
ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for
additional manifestations of a basilar skull fracture. What
assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ansRhinorrhoea or otorrhoea with Halo sign.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is
consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm
fractures. (C) occurs with blunt abdominal injuries.
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter
tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her
deceased husband. What nursing problem best describes this problem?
A. Confusion related to recent death of loved one.
B. Unresolved anger related to death of husband.
C. Delayed grief reaction related to death of husband.
D. Denial related to the loss of a loved one - ansD. Denial related to the loss of a loved one.
RATIONALE:
Based on the data provided, (C) is the best nursing diagnosis. This client is exhibiting symptoms
of anxiety and the pain is too great for her to acknowledge, so she is denying the situation.
Although she may seem confused (A), she is actually trying to deal with the pain through the
defense mechanism of denial. (B) occurs after one year or longer following the loss. The client's
