NR 316: Critical Care HESI Practice Ultimate Study Bank
with Detailed Rationales — Part 1 (Questions 1–65)
Course Code: NR 316
Course Name: Critical Care Nursing
Topic: Advanced Adult Clinical Care, Triage Systems, Trauma, Fluid
Resuscitation, and Professional Ethics
Academic Year: 2026/2027
1. A nurse in an emergency department is providing postprocedure care to a
client who had a cardiac catheterization. The client begins to manifest signs
and symptoms associated with embolization. Which action should the nurse
take?
A. Notify the primary healthcare provider immediately
B. Apply a warm, moist compress to the incision site
C. Increase the intravenous fluid rate by 20 mL/hr
D. Monitor vital signs more frequently
CORRECT ANSWER: A
RATIONALE: Post-cardiac catheterization embolization is a life-threatening
complication where a displaced plaque or thrombus obstructs peripheral or
systemic arterial blood flow. The nurse must notify the primary healthcare
provider immediately to initiate emergent surgical or pharmacological
interventions (such as embolectomy or thrombolytic therapy). Applying heat is
contraindicated as it increases local metabolic demands in an ischemic limb.
Increasing the IV rate does not resolve mechanical arterial occlusion. While
increasing the frequency of vital sign checks is appropriate, it delays the definitive
medical intervention required to preserve life or limb tissue.
2. A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The
nurse rushes to the scene and determines that the person is in
cardiopulmonary arrest. What should the nurse do first?
A. Feel for a pulse
B. Begin chest compressions
C. Leave to call for assistance
D. Perform the abdominal thrust maneuver
, CORRECT ANSWER: B
RATIONALE: According to the standard Basic Life Support (BLS) and
cardiopulmonary resuscitation (CPR) guidelines for an unwitnessed out-of-hospital
cardiac arrest, once unresponsiveness and lack of breathing are established, the
rescuer must immediately begin high-quality chest compressions. High-quality
chest compressions maintain perfusion to the brain and myocardium. Leaving the
scene delays critical circulatory support, and a formal pulse check is streamlined
within the initial response window to prevent delay of compressions. Abdominal
thrusts are reserved for airway obstructions caused by foreign bodies, not trauma-
induced arrest.
3. A client reports left-sided chest pain after playing racquetball. The client is
hospitalized and diagnosed with left pneumothorax. When assessing the
client's left chest area, the nurse expects to identify which finding?
A. Dull sound on percussion
B. Vocal fremitus on palpation
C. Rales with rhonchi on auscultation
D. Absence of breath sounds on auscultation
CORRECT ANSWER: D
RATIONALE: A pneumothorax involves the accumulation of air within the
pleural space, which collapses the underlying lung tissue. Because the lung cannot
expand against the trapped intrapleural air, the nurse will note an absence of
breath sounds on auscultation over the affected lung fields. Percussion over an
air-filled, hyperinflated space yields hyperresonance, not a dull sound (which
indicates fluid or consolidation). Vocal fremitus is decreased or absent because air
dampens sound vibrations, and rales or rhonchi cannot be produced in a collapsed,
non-ventilating lung segment.
4. A client is admitted to the hospital with partial- and full-thickness burns of
the chest and face sustained while trying to extinguish a brush fire. Which is
the nurse's priority concern?
A. Loss of skin integrity caused by the burns
B. Potential infection as a result of the burn injury
C. Inadequate gas exchange caused by smoke inhalation
D. Decreased fluid volume because of the depth of the burns
, CORRECT ANSWER: C
RATIONALE: Utilizing the airway, breathing, circulation (ABC) clinical
prioritization framework, inadequate gas exchange caused by smoke inhalation
takes absolute precedence during the emergent phase of burn care. Facial and chest
burns carry an extremely high risk for upper airway edema, carbon monoxide
poisoning, thermal airway injury, and bronchospasm. While managing fluid
resuscitation, preventing systemic infections, and restoring skin integrity are vital
elements of comprehensive burn management, they are secondary to securing a
patent airway and maintaining alveolar gas exchange.
5. During the first 48 hours after a client has sustained a thermal injury,
which conditions should the nurse assess for?
A. Hypokalemia and hyponatremia
B. Hyperkalemia and hyponatremia
C. Hypokalemia and hypernatremia
D. Hyperkalemia and hypernatremia
CORRECT ANSWER: B
RATIONALE: In the emergent phase of a thermal injury (the first 24 to 48
hours), massive cellular destruction releases large amounts of intracellular
potassium into the extracellular fluid, resulting in hyperkalemia. Concurrently,
widespread capillary permeability allows plasma fluids and electrolytes to leak into
the interstitial spaces, while sodium shifts directly into the cells, presenting as
hyponatremia. The nurse must monitor for these imbalances, as hyperkalemia can
trigger fatal cardiac dysrhythmias.
6. A nurse is assessing a client's ECG reading. The client's atrial and
ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14
seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P
waves and QRS complexes. How will the nurse interpret this rhythm?
A. Normal sinus rhythm
B. Sinus tachycardia
C. Sinus bradycardia
D. Sinus arrhythmia
CORRECT ANSWER: A
RATIONALE: This rhythm meets all the strict criteria for a normal sinus
with Detailed Rationales — Part 1 (Questions 1–65)
Course Code: NR 316
Course Name: Critical Care Nursing
Topic: Advanced Adult Clinical Care, Triage Systems, Trauma, Fluid
Resuscitation, and Professional Ethics
Academic Year: 2026/2027
1. A nurse in an emergency department is providing postprocedure care to a
client who had a cardiac catheterization. The client begins to manifest signs
and symptoms associated with embolization. Which action should the nurse
take?
A. Notify the primary healthcare provider immediately
B. Apply a warm, moist compress to the incision site
C. Increase the intravenous fluid rate by 20 mL/hr
D. Monitor vital signs more frequently
CORRECT ANSWER: A
RATIONALE: Post-cardiac catheterization embolization is a life-threatening
complication where a displaced plaque or thrombus obstructs peripheral or
systemic arterial blood flow. The nurse must notify the primary healthcare
provider immediately to initiate emergent surgical or pharmacological
interventions (such as embolectomy or thrombolytic therapy). Applying heat is
contraindicated as it increases local metabolic demands in an ischemic limb.
Increasing the IV rate does not resolve mechanical arterial occlusion. While
increasing the frequency of vital sign checks is appropriate, it delays the definitive
medical intervention required to preserve life or limb tissue.
2. A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The
nurse rushes to the scene and determines that the person is in
cardiopulmonary arrest. What should the nurse do first?
A. Feel for a pulse
B. Begin chest compressions
C. Leave to call for assistance
D. Perform the abdominal thrust maneuver
, CORRECT ANSWER: B
RATIONALE: According to the standard Basic Life Support (BLS) and
cardiopulmonary resuscitation (CPR) guidelines for an unwitnessed out-of-hospital
cardiac arrest, once unresponsiveness and lack of breathing are established, the
rescuer must immediately begin high-quality chest compressions. High-quality
chest compressions maintain perfusion to the brain and myocardium. Leaving the
scene delays critical circulatory support, and a formal pulse check is streamlined
within the initial response window to prevent delay of compressions. Abdominal
thrusts are reserved for airway obstructions caused by foreign bodies, not trauma-
induced arrest.
3. A client reports left-sided chest pain after playing racquetball. The client is
hospitalized and diagnosed with left pneumothorax. When assessing the
client's left chest area, the nurse expects to identify which finding?
A. Dull sound on percussion
B. Vocal fremitus on palpation
C. Rales with rhonchi on auscultation
D. Absence of breath sounds on auscultation
CORRECT ANSWER: D
RATIONALE: A pneumothorax involves the accumulation of air within the
pleural space, which collapses the underlying lung tissue. Because the lung cannot
expand against the trapped intrapleural air, the nurse will note an absence of
breath sounds on auscultation over the affected lung fields. Percussion over an
air-filled, hyperinflated space yields hyperresonance, not a dull sound (which
indicates fluid or consolidation). Vocal fremitus is decreased or absent because air
dampens sound vibrations, and rales or rhonchi cannot be produced in a collapsed,
non-ventilating lung segment.
4. A client is admitted to the hospital with partial- and full-thickness burns of
the chest and face sustained while trying to extinguish a brush fire. Which is
the nurse's priority concern?
A. Loss of skin integrity caused by the burns
B. Potential infection as a result of the burn injury
C. Inadequate gas exchange caused by smoke inhalation
D. Decreased fluid volume because of the depth of the burns
, CORRECT ANSWER: C
RATIONALE: Utilizing the airway, breathing, circulation (ABC) clinical
prioritization framework, inadequate gas exchange caused by smoke inhalation
takes absolute precedence during the emergent phase of burn care. Facial and chest
burns carry an extremely high risk for upper airway edema, carbon monoxide
poisoning, thermal airway injury, and bronchospasm. While managing fluid
resuscitation, preventing systemic infections, and restoring skin integrity are vital
elements of comprehensive burn management, they are secondary to securing a
patent airway and maintaining alveolar gas exchange.
5. During the first 48 hours after a client has sustained a thermal injury,
which conditions should the nurse assess for?
A. Hypokalemia and hyponatremia
B. Hyperkalemia and hyponatremia
C. Hypokalemia and hypernatremia
D. Hyperkalemia and hypernatremia
CORRECT ANSWER: B
RATIONALE: In the emergent phase of a thermal injury (the first 24 to 48
hours), massive cellular destruction releases large amounts of intracellular
potassium into the extracellular fluid, resulting in hyperkalemia. Concurrently,
widespread capillary permeability allows plasma fluids and electrolytes to leak into
the interstitial spaces, while sodium shifts directly into the cells, presenting as
hyponatremia. The nurse must monitor for these imbalances, as hyperkalemia can
trigger fatal cardiac dysrhythmias.
6. A nurse is assessing a client's ECG reading. The client's atrial and
ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14
seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P
waves and QRS complexes. How will the nurse interpret this rhythm?
A. Normal sinus rhythm
B. Sinus tachycardia
C. Sinus bradycardia
D. Sinus arrhythmia
CORRECT ANSWER: A
RATIONALE: This rhythm meets all the strict criteria for a normal sinus
