Test Bank: Hesi critical thinking/
Critical Care Latest Update Question
with Verified Answers Key Download
Graded A+
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting
from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this
client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach items on the floor.
B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
C. It is safe to use a walker to get out of bed, but you need assistance when walking.
D. Take pain medication 30 minutes after your physical therapy sessions. - Correct Answers-The
client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation
for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a
pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid
bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker
or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than
waiting until the pain level is high after their therapy.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV
q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention
for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - Correct
Answers-To ensure that a therapeutic level of medication is maintained, the nurse should administer the
missed dose as soon as possible, and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the
reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the
drug.
Correct Answer: D
,A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site.
The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which
action should the nurse take at this time?
A. Administer the medication more rapidly using the same IV site.
B. Initiate an alternate site for the IV infusion of the medication.
C. Notify the healthcare provider before administering the next dose.
D. Give the client a PRN dose of aspirin while the medication infuses. - Correct Answers-A
cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site
minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before
administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel
irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site.
Although aspirin has antiinflammatory actions, (D) is not indicated.
Correct Answer: B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should
the nurse set the client's intravenous infusion pump?
A. 13 ml/hour.
B. 63 ml/hour.
C. 80 ml/hour.
D. 125 ml/hour. - Correct Answers-(B) is the correct calculation: To calculate this problem correctly,
remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour.
Correct Answer: B
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy
diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how
many ml/hr should the infusion pump be set to deliver the secondary infusion? - Correct Answers-The
infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply
extremes and means 50 × 60 /20x 1= 300/20=150
Correct Answer: 150
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is
most important for the nurse to include during the preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?
C. Do you feel that you are overweight?
D. Will a clear liquid diet be okay after surgery? - Correct Answers-Vitamin and mineral supplements
(B) may impact medications used during the operative period. (A and C) are appropriate questions for
long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear
liquid diet (D), rather than the client's preference.
, Correct Answer: B
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have
for planning care in terms of the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. - Correct Answers-Blood transfusions are forbidden (B) in the
Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of
these sects are vegetarian (D), but the direct impact on nursing care is (B).
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider
prescribes an analgesic every four hours as needed. Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. - Correct Answers-The
most effective management of pain is achieved using an around-the-clock schedule that provides
analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain
persists until it is severe, so an analgesic medication should be administered before the client's pain peaks
(B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability
to interact and experience the time before life ends should be minimized (C). Offering a medication-free
period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as
rapidly as possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up.
C. Monitor vital signs q15 minutes for the first hour.
D. Ensure the accuracy of the blood type match. - Correct Answers-All interventions should be
implemented prior to administering blood, but (D) has the highest priority. Any time blood is
administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible
hemolytic reaction.
Correct Answer: D
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse
take?
Critical Care Latest Update Question
with Verified Answers Key Download
Graded A+
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting
from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this
client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach items on the floor.
B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
C. It is safe to use a walker to get out of bed, but you need assistance when walking.
D. Take pain medication 30 minutes after your physical therapy sessions. - Correct Answers-The
client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation
for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a
pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid
bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker
or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than
waiting until the pain level is high after their therapy.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV
q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention
for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. - Correct
Answers-To ensure that a therapeutic level of medication is maintained, the nurse should administer the
missed dose as soon as possible, and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the
reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the
drug.
Correct Answer: D
,A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site.
The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which
action should the nurse take at this time?
A. Administer the medication more rapidly using the same IV site.
B. Initiate an alternate site for the IV infusion of the medication.
C. Notify the healthcare provider before administering the next dose.
D. Give the client a PRN dose of aspirin while the medication infuses. - Correct Answers-A
cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site
minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before
administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel
irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site.
Although aspirin has antiinflammatory actions, (D) is not indicated.
Correct Answer: B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should
the nurse set the client's intravenous infusion pump?
A. 13 ml/hour.
B. 63 ml/hour.
C. 80 ml/hour.
D. 125 ml/hour. - Correct Answers-(B) is the correct calculation: To calculate this problem correctly,
remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour.
Correct Answer: B
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy
diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how
many ml/hr should the infusion pump be set to deliver the secondary infusion? - Correct Answers-The
infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply
extremes and means 50 × 60 /20x 1= 300/20=150
Correct Answer: 150
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is
most important for the nurse to include during the preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?
C. Do you feel that you are overweight?
D. Will a clear liquid diet be okay after surgery? - Correct Answers-Vitamin and mineral supplements
(B) may impact medications used during the operative period. (A and C) are appropriate questions for
long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear
liquid diet (D), rather than the client's preference.
, Correct Answer: B
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have
for planning care in terms of the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. - Correct Answers-Blood transfusions are forbidden (B) in the
Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of
these sects are vegetarian (D), but the direct impact on nursing care is (B).
Correct Answer: B
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider
prescribes an analgesic every four hours as needed. Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities. - Correct Answers-The
most effective management of pain is achieved using an around-the-clock schedule that provides
analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain
persists until it is severe, so an analgesic medication should be administered before the client's pain peaks
(B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability
to interact and experience the time before life ends should be minimized (C). Offering a medication-free
period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as
rapidly as possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up.
C. Monitor vital signs q15 minutes for the first hour.
D. Ensure the accuracy of the blood type match. - Correct Answers-All interventions should be
implemented prior to administering blood, but (D) has the highest priority. Any time blood is
administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible
hemolytic reaction.
Correct Answer: D
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse
take?
