CRITICAL CARE HESI COMPREHENSIVE STUDY
GUIDE WITH SOLUTIONS
◉ The Nurse is caring for a client admitted to the intensive care unit
with shortness of breath and abdominal pain one week after
undergoing bariatric surgery. The client's current vital signs are
rectal temperature 101.5 F, heart rate 132 bpm, respirations 20 bpm,
blood pressure 88/50 mmHg, and oxygen saturation 94%. Which
intervention should the nurse implement first?
a. Administer a prescribed PRN antipyretic.
b. Transport to radiology for an abdominal x-ray.
c. Apply oxygen at 2 liters per nasal cannula.
d. Infuse a 1,000 mL normal saline bolus.
Answer: Infuse a 1,000 mL normal saline bolus.
◉ The nurse is evaluating a client's central venous pressure (CVP)
readings that are trending upwards. Which nursing problem is
supported by the pathophysiologic mechanism most likely causing
the increases?
a. Decreased cardiac output.
b. Ineffective peripheral tissue perfusion.
c. Deficient fluid volume.
d. Ineffective airway clearance.
,Answer: Decreased cardiac output.
◉ A client who is admitted to the emergency room following a
motorcycle accident is having difficulty breathing. While assessing
the client's chest and lungs, the nurse notes that there are no breath
sounds over the left fields. Which actions should the nurse
implement? (Select all that apply)
a. Place client in Trendelenburg position.
b. Apply a high-flow oxygen by face mask
c. Elevate the head of the bed 45 degrees
d. Withhold narcotic pain medication.
e. Obtain a chest tube insertion kit.
Answer: b. Apply a high-flow oxygen by face mask
c. Elevate the head of the bed 45 degrees
e. Obtain a chest tube insertion kit
◉ Five days after admission to the intensive care unit, a client
remains confused to time and place even after frequent attempts at
reorientation. Which intervention should the nurse implement to
ensure the client's safety?
a. Ask the family to obtain a 24-hour sitter.
b. Increase the frequency of direct observation.
c. Apply a vest restraint.
d. Administer a PRN sedative.
, Answer: Increase the frequency of direct observation.
◉ A client with a pulmonary embolism is receiving streptokinase
100,000 international units (IU)/hour for the next 24 hours. The
pharmacy dispensed streptokinase 1,500,000 IU in 500 mL of 0.9%
normal saline. The nurse should program the infusion pump to
deliver how many mL/hr? (Enter numeric value only, and round to
the nearest whole number)
Answer: 15
◉ A client who experiences multiple traumatic injuries begins to
ooze blood from an injection site. Which additional finding should
the nurse identify that supports an early indication of disseminated
intravascular coagulation (DIC)?
a. Negative D-dimer test.
b. Edema of the extremities.
c. Shorter clotting times.
d. Bleeding from oral mucosa.
Answer: Edema of the extremities.
◉ The vital signs for a client with heart failure, who is admitted to
the intensive care unit are temperature, 98.6F, heart rate 125 bpm,
respirations 22 bpm, and blood pressure 140/50 mmHg. The nurse
determines the client's central venous pressure (CVP) and
GUIDE WITH SOLUTIONS
◉ The Nurse is caring for a client admitted to the intensive care unit
with shortness of breath and abdominal pain one week after
undergoing bariatric surgery. The client's current vital signs are
rectal temperature 101.5 F, heart rate 132 bpm, respirations 20 bpm,
blood pressure 88/50 mmHg, and oxygen saturation 94%. Which
intervention should the nurse implement first?
a. Administer a prescribed PRN antipyretic.
b. Transport to radiology for an abdominal x-ray.
c. Apply oxygen at 2 liters per nasal cannula.
d. Infuse a 1,000 mL normal saline bolus.
Answer: Infuse a 1,000 mL normal saline bolus.
◉ The nurse is evaluating a client's central venous pressure (CVP)
readings that are trending upwards. Which nursing problem is
supported by the pathophysiologic mechanism most likely causing
the increases?
a. Decreased cardiac output.
b. Ineffective peripheral tissue perfusion.
c. Deficient fluid volume.
d. Ineffective airway clearance.
,Answer: Decreased cardiac output.
◉ A client who is admitted to the emergency room following a
motorcycle accident is having difficulty breathing. While assessing
the client's chest and lungs, the nurse notes that there are no breath
sounds over the left fields. Which actions should the nurse
implement? (Select all that apply)
a. Place client in Trendelenburg position.
b. Apply a high-flow oxygen by face mask
c. Elevate the head of the bed 45 degrees
d. Withhold narcotic pain medication.
e. Obtain a chest tube insertion kit.
Answer: b. Apply a high-flow oxygen by face mask
c. Elevate the head of the bed 45 degrees
e. Obtain a chest tube insertion kit
◉ Five days after admission to the intensive care unit, a client
remains confused to time and place even after frequent attempts at
reorientation. Which intervention should the nurse implement to
ensure the client's safety?
a. Ask the family to obtain a 24-hour sitter.
b. Increase the frequency of direct observation.
c. Apply a vest restraint.
d. Administer a PRN sedative.
, Answer: Increase the frequency of direct observation.
◉ A client with a pulmonary embolism is receiving streptokinase
100,000 international units (IU)/hour for the next 24 hours. The
pharmacy dispensed streptokinase 1,500,000 IU in 500 mL of 0.9%
normal saline. The nurse should program the infusion pump to
deliver how many mL/hr? (Enter numeric value only, and round to
the nearest whole number)
Answer: 15
◉ A client who experiences multiple traumatic injuries begins to
ooze blood from an injection site. Which additional finding should
the nurse identify that supports an early indication of disseminated
intravascular coagulation (DIC)?
a. Negative D-dimer test.
b. Edema of the extremities.
c. Shorter clotting times.
d. Bleeding from oral mucosa.
Answer: Edema of the extremities.
◉ The vital signs for a client with heart failure, who is admitted to
the intensive care unit are temperature, 98.6F, heart rate 125 bpm,
respirations 22 bpm, and blood pressure 140/50 mmHg. The nurse
determines the client's central venous pressure (CVP) and
