HESI RN Critical Care Exam |
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Rationales| Brand new!!| Latest
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The nurse is calculating fluid resuscitation for a young adult male who sustained burns in
an industrial accident at 1200 and is seen in the emergency department at 1400. The
healthcare provider determines that the client has burns over 30% of his body surface
area, primarily over his 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
establish for this client's plan of care?
a. By 2000, the client will have received 2000 mL of fluid
b. By 2000, the client will have received 3500 mL of fluid
c. By 2400, the client will have received 7000 mL of fluid
d. By 1200 the following day, the client will have received 7000 mL of fluid
✔️ Correct Answer: B
Rationale:
The Parkland formula dictates that half of the total 24-hour fluid requirement should be
administered during the first 8 hours following the burn injury. The client was injured at
1200 and arrived at 1400, so the 8-hour window extends from 1200 to 2000. Therefore,
by 2000, the client should have received 3500 mL (half of 7000 mL). This ensures
adequate resuscitation during the initial phase of burn shock when capillary permeability
is greatest and fluid shifts are most pronounced.
Option A is incorrect because 2000 mL is insufficient and does not represent half of the
prescribed total. Option C is incorrect because the total 24-hour volume should be
completed by 1200 the following day, not by 2400. Option D is incorrect because while
this represents the total 24-hour completion time, the goal should specify the 8-hour
midpoint requirement.
When caring for a client on mechanical ventilation, which finding provides the greatest
indication that the client has an open airway?
a. The ventilator delivers the prescribed tidal volume
b. Bilateral breath sounds can be auscultated
c. The client's oxygen saturation is above 92%
d. The endotracheal tube is properly secured
✔️ Correct Answer: B
Rationale:
Auscultation of bilateral breath sounds (Option B) provides the greatest indication of an
open airway and proper endotracheal tube placement. Equal bilateral breath sounds
confirm that air is entering both lungs and that the tube has not migrated into the right
mainstem bronchus, which would cause diminished or absent breath sounds on the left
,side. This assessment is the most reliable bedside indicator of airway patency and correct
tube placement.
Option A is incorrect because the ventilator may deliver tidal volume even if there is a
leak or obstruction; this does not confirm an open airway. Option C is incorrect because
oxygen saturation may be maintained with a partially obstructed airway or with high FiO₂.
Option D is incorrect because a secured tube may still be malpositioned or obstructed.
The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted with a subarachnoid hemorrhage (stroke). The client's Glasgow
Coma Scale (GCS) score is 9. What information is most important for the nurse to
determine?
a. The client's previous GCS score
b. The client's blood pressure reading
c. The time of the client's last meal
d. The client's family history of stroke
✔️ Correct Answer: A
Rationale:
Determining the client's previous GCS score (Option A) is the most important information
when assessing a client with a GCS of 9. A GCS score of 9 indicates moderate to severe
neurological impairment. Comparing the current score to the previous score allows the
nurse to identify trends in neurological status, such as deterioration or improvement. A
declining GCS score is a critical indicator of increasing intracranial pressure or ongoing
neurological injury.
Option B is incorrect while blood pressure is important, the trend in GCS is the priority for
neurological assessment. Option C is incorrect because the time of the last meal is not
the priority. Option D is incorrect because family history does not provide immediate
information about current neurological status.
, An adult female with a history of type 1 diabetes has been vomiting for the past 48 hours
and is admitted to the ICU with diabetic ketoacidosis (DKA). Which assessment finding
warrants immediate intervention by the nurse?
a. Excessive thirst
b. Kussmaul respirations
c. Blood glucose of 450 mg/dL
d. Serum potassium of 3.0 mEq/L
✔️ Correct Answer: D
Rationale:
A serum potassium of 3.0 mEq/L (Option D) warrants immediate intervention.
Hypokalemia in DKA is a life-threatening electrolyte imbalance that can cause cardiac
arrhythmias, muscle weakness, and respiratory paralysis. Insulin therapy will drive
potassium into cells, further lowering serum potassium levels. Potassium replacement
should be initiated before or concurrently with insulin therapy to prevent severe
hypokalemia.
Option A is incorrect because excessive thirst (polydipsia) is a symptom of hyperglycemia
but does not require immediate intervention. Option B is incorrect because Kussmaul
respirations are a compensatory mechanism for metabolic acidosis and require
intervention, but hypokalemia is more immediately life-threatening. Option C is incorrect
because a blood glucose of 450 mg/dL is expected in DKA and requires treatment but is
not the priority over severe hypokalemia.
A client admitted to the ICU after a colon resection with the formation of a loop
colostomy has a clean, dry abdominal dressing. Vital signs are: heart rate 130,
temperature 100°F, blood pressure 88/65, and urine output of 10 mL/hr. What
interventions should the nurse implement?
a. Give a 500 mL IV fluid bolus challenge
b. Administer antipyretics
c. Notify the healthcare provider of vital signs
d. Document findings and continue monitoring
✔️ Correct Answer: A
Rationale:
Exit Exam | 200+ Questions with
Verified Answers & Detailed
Rationales| Brand new!!| Latest
2026/2027 Frequently Most Tested Questions and 100%
Accurate From Past papers | Graded A+ , Reviewed and
Updated | 100% Guarantee Pass | Latest Exam and
Newest Version!!!
The nurse is calculating fluid resuscitation for a young adult male who sustained burns in
an industrial accident at 1200 and is seen in the emergency department at 1400. The
healthcare provider determines that the client has burns over 30% of his body surface
area, primarily over his 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
establish for this client's plan of care?
a. By 2000, the client will have received 2000 mL of fluid
b. By 2000, the client will have received 3500 mL of fluid
c. By 2400, the client will have received 7000 mL of fluid
d. By 1200 the following day, the client will have received 7000 mL of fluid
✔️ Correct Answer: B
Rationale:
The Parkland formula dictates that half of the total 24-hour fluid requirement should be
administered during the first 8 hours following the burn injury. The client was injured at
1200 and arrived at 1400, so the 8-hour window extends from 1200 to 2000. Therefore,
by 2000, the client should have received 3500 mL (half of 7000 mL). This ensures
adequate resuscitation during the initial phase of burn shock when capillary permeability
is greatest and fluid shifts are most pronounced.
Option A is incorrect because 2000 mL is insufficient and does not represent half of the
prescribed total. Option C is incorrect because the total 24-hour volume should be
completed by 1200 the following day, not by 2400. Option D is incorrect because while
this represents the total 24-hour completion time, the goal should specify the 8-hour
midpoint requirement.
When caring for a client on mechanical ventilation, which finding provides the greatest
indication that the client has an open airway?
a. The ventilator delivers the prescribed tidal volume
b. Bilateral breath sounds can be auscultated
c. The client's oxygen saturation is above 92%
d. The endotracheal tube is properly secured
✔️ Correct Answer: B
Rationale:
Auscultation of bilateral breath sounds (Option B) provides the greatest indication of an
open airway and proper endotracheal tube placement. Equal bilateral breath sounds
confirm that air is entering both lungs and that the tube has not migrated into the right
mainstem bronchus, which would cause diminished or absent breath sounds on the left
,side. This assessment is the most reliable bedside indicator of airway patency and correct
tube placement.
Option A is incorrect because the ventilator may deliver tidal volume even if there is a
leak or obstruction; this does not confirm an open airway. Option C is incorrect because
oxygen saturation may be maintained with a partially obstructed airway or with high FiO₂.
Option D is incorrect because a secured tube may still be malpositioned or obstructed.
The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted with a subarachnoid hemorrhage (stroke). The client's Glasgow
Coma Scale (GCS) score is 9. What information is most important for the nurse to
determine?
a. The client's previous GCS score
b. The client's blood pressure reading
c. The time of the client's last meal
d. The client's family history of stroke
✔️ Correct Answer: A
Rationale:
Determining the client's previous GCS score (Option A) is the most important information
when assessing a client with a GCS of 9. A GCS score of 9 indicates moderate to severe
neurological impairment. Comparing the current score to the previous score allows the
nurse to identify trends in neurological status, such as deterioration or improvement. A
declining GCS score is a critical indicator of increasing intracranial pressure or ongoing
neurological injury.
Option B is incorrect while blood pressure is important, the trend in GCS is the priority for
neurological assessment. Option C is incorrect because the time of the last meal is not
the priority. Option D is incorrect because family history does not provide immediate
information about current neurological status.
, An adult female with a history of type 1 diabetes has been vomiting for the past 48 hours
and is admitted to the ICU with diabetic ketoacidosis (DKA). Which assessment finding
warrants immediate intervention by the nurse?
a. Excessive thirst
b. Kussmaul respirations
c. Blood glucose of 450 mg/dL
d. Serum potassium of 3.0 mEq/L
✔️ Correct Answer: D
Rationale:
A serum potassium of 3.0 mEq/L (Option D) warrants immediate intervention.
Hypokalemia in DKA is a life-threatening electrolyte imbalance that can cause cardiac
arrhythmias, muscle weakness, and respiratory paralysis. Insulin therapy will drive
potassium into cells, further lowering serum potassium levels. Potassium replacement
should be initiated before or concurrently with insulin therapy to prevent severe
hypokalemia.
Option A is incorrect because excessive thirst (polydipsia) is a symptom of hyperglycemia
but does not require immediate intervention. Option B is incorrect because Kussmaul
respirations are a compensatory mechanism for metabolic acidosis and require
intervention, but hypokalemia is more immediately life-threatening. Option C is incorrect
because a blood glucose of 450 mg/dL is expected in DKA and requires treatment but is
not the priority over severe hypokalemia.
A client admitted to the ICU after a colon resection with the formation of a loop
colostomy has a clean, dry abdominal dressing. Vital signs are: heart rate 130,
temperature 100°F, blood pressure 88/65, and urine output of 10 mL/hr. What
interventions should the nurse implement?
a. Give a 500 mL IV fluid bolus challenge
b. Administer antipyretics
c. Notify the healthcare provider of vital signs
d. Document findings and continue monitoring
✔️ Correct Answer: A
Rationale:
