Critical Care HESI Exam Questions and answers EXAM, SOLUTIONS
HESI Critical Care Exam
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1. A 56-year-old female client is re- B. A nurse with Marfan's syndrome who is post-
ceiving intracavitary radiation via a menopausal.
radium implant. Which RATIONALE:
nurse should be assigned to care A client receiving intracavity radiation poses a radiation
for this client? hazard as long as the intracavity
A. The nurse who is caring for an- radiation source is in place. A nurse's ability to care of
other client receiving intracavitary this client is not affected by Marfan's
radiation. syndrome (B), which is a hereditary disorder of con-
B. A nurse with Marfan's syndrome nective tissues, bones, muscles, ligaments
who is postmenopausal. and skeletal structures. The goal is to limit any one staff
C. A nurse with oncology experi- member's exposure to the calculated
ence who may be pregnant. time span based on the half-life of radium, such as the
D. The nurse who is caring for an- number of minutes at the bedside per day,
other client who has Clostridium so (A) should not be assigned. (C) should not be ex-
difficile. posed 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 transmis-
sion of an infectious organism (D).
2. 1.A client who has active tuberculo- Assign the client to a negative air-flow room
sis (TB) is admitted to the medical RATIONALE:
unit. What action is most Active tuberculosis requires implementation of air-
important for the nurse to imple- borne precautions, so the client should be
ment? assigned to a negative pressure air-flow room (D). Al-
A. Fit the client with a respirator though (A and C) should be implemented
mask. for clients in isolation with contact precautions, it is
B. Assign the client to a negative most important that air flow from the room
air-flow room. is minimized when the client has TB. (B) should be
C. Don a clean gown for client implemented when the client leaves the
care. isolation environment.
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D. Place an isolation cart in the hall-
way
3. 2.A client is receiving atenolol Administer the medication
(Tenormin) 25 mg PO after a my- RATIONALE:
ocardial infarction. The nurse Atenolol, a beta-blocker, blocks the beta receptors of
determines the client's apical pulse the sinoatrial node to reduce the heart rate,
is 65 beats per minute. What action so the medication should be administered (C) because
should the nurse the client's apical pulse is greater than 60.
implement (A, B, and D) are not indicated at this time.
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication.
4. 3.The nurse is assessing a client Hyperthyroidism
and identifies a bruit over the thy- Rationale:Hyperthyroidism (D) is an enlargement of the
roid. This finding is consistent thyroid gland, often referred to as a goiter, and a
with which interpretation? bruit may be auscultated over the goiter due to an
A. Hypothyroidism. increase in glandular vascularity which
B. Thyroid cyst. increases as the thyroid gland becomes hyperactive. A
C. Thyroid cancer. bruit is not common with (A, B, and C).
D. Hyperthyroidism
5. A 6-year-old child is alert but qui- Rhinorrhoea or otorrhoea with Halo sign.
et when brought to the emergency RATIONALE:
center with periorbital ecchymosis Raccoon eyes (periorbital ecchymosis) and Battle's sign
and ecchymosis behind the ears. (ecchymosis behind the ear over the
The nurse suspects potential child mastoid process) are both signs of a basilar skull frac-
abuse and continues to assess the ture, so the nurse should assess for possible
child for additional manifestations meningeal tears that manifest as a Halo sign with CSF
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of a basilar skull fracture. What leakage from the ears or nose (D). (A) is
assessment finding would be con- consistent with orbital fractures. (B) occurs with
sistent with a basilar skull frac- wrenching traumas of the shoulder or arm
ture? fractures. (C) occurs with blunt abdominal injuries.
A. Hematemesis and abdominal
distention.
B. Asymmetry of the face and eye
movements.
C. Rhinorrhoea or otorrhoea with
Halo sign.
D. Abnormal position and move-
ment of the arm.
6. The nurse is assessing a client who Grave's disease
complains of weight loss, racing RATIONALE:
heart rate, and difficulty This client is exhibiting symptoms associated with hy-
sleeping. The nurse determines perthyroidism or Grave's disease (A),
the client has moist skin with fine which is an autoimmune condition affecting the thy-
hair, prominent eyes, lid roid. (B, C, and D) are not associated with
retraction, and a staring expres- these symptoms.
sion. These findings are consistent
with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome.
7. The nurse is assessing an old- Ptosis on the left eyelid
er client and determines that the Rationale: Ptosis is the term to describe an eyelid droop
client's left upper eyelid droops, that covers a large portion of the iris (A), which
covering more of the iris than may result from oculomotor nerve or eyelid muscle
the right eyelid. Which description disorder. (B) is characterized by rapid,
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should the nurse use to rhythmic movement of both eyes. (C) is a distortion of
document this finding? the lens of the eye, causing decreased
A. A nystagmus on the left. visual acuity. (D) is a term used to describe a protrusion
B. Exophthalmos on the right. of the eyeballs that occurs with
C. Ptosis on the left eyelid. hyperthyroidism.
D. Astigmatism on the right.
8. The nurse is assessing a child's A. Question the type and quantity of foods eaten in a
weight and height during a clinic typical day.
visit prior to starting school. RATIONALE:
The nurse plots the child's weight The child is overweight for height, so assessment of the
on the growth chart and notes that child's daily diet (C) should be
the child's weight is in the determined. The child does not need (A or B), both of
95th percentile for the child's which will increase the child's weight.
height. What action should the Poor nutrition (D) is commonly seen in underweight
nurse take? children, not overweight.
A. Question the type and quantity
of foods eaten in a typical day.
B. Encourage giving two additional
snacks each day to the child.
C. Recommend a daily intake of at
least four glasses of whole milk.
D. Assess for signs of poor nutri-
tion, such as a pale appearance
9. A child is receiving maintenance in- B. 61
travenous (IV) fluids at the rate of RATIONALE:
1000 mL for the first 10 The formula for calculating daily fluid requirements is:
kg of body weight, plus 50 mL/kg 0 to 10 kg, 100 mL/kg per day; or 10 to
per day for each kilogram between 20 kg, 1000 mL for the first 10 kg of body weight plus
10 and 20. How many 50 mL/kg per day for each kilogram
milliliters per hour should the between 10 and 20. To determine an hourly rate, divide
HESI Critical Care Exam
(MULTIPLE CHOICES) 100% correct 2025!!
Study online at https://quizlet.com/_c8s6s8
1. A 56-year-old female client is re- B. A nurse with Marfan's syndrome who is post-
ceiving intracavitary radiation via a menopausal.
radium implant. Which RATIONALE:
nurse should be assigned to care A client receiving intracavity radiation poses a radiation
for this client? hazard as long as the intracavity
A. The nurse who is caring for an- radiation source is in place. A nurse's ability to care of
other client receiving intracavitary this client is not affected by Marfan's
radiation. syndrome (B), which is a hereditary disorder of con-
B. A nurse with Marfan's syndrome nective tissues, bones, muscles, ligaments
who is postmenopausal. and skeletal structures. The goal is to limit any one staff
C. A nurse with oncology experi- member's exposure to the calculated
ence who may be pregnant. time span based on the half-life of radium, such as the
D. The nurse who is caring for an- number of minutes at the bedside per day,
other client who has Clostridium so (A) should not be assigned. (C) should not be ex-
difficile. posed 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 transmis-
sion of an infectious organism (D).
2. 1.A client who has active tuberculo- Assign the client to a negative air-flow room
sis (TB) is admitted to the medical RATIONALE:
unit. What action is most Active tuberculosis requires implementation of air-
important for the nurse to imple- borne precautions, so the client should be
ment? assigned to a negative pressure air-flow room (D). Al-
A. Fit the client with a respirator though (A and C) should be implemented
mask. for clients in isolation with contact precautions, it is
B. Assign the client to a negative most important that air flow from the room
air-flow room. is minimized when the client has TB. (B) should be
C. Don a clean gown for client implemented when the client leaves the
care. isolation environment.
, HESI Critical Care Exam
Study online at https://quizlet.com/_c8s6s8
D. Place an isolation cart in the hall-
way
3. 2.A client is receiving atenolol Administer the medication
(Tenormin) 25 mg PO after a my- RATIONALE:
ocardial infarction. The nurse Atenolol, a beta-blocker, blocks the beta receptors of
determines the client's apical pulse the sinoatrial node to reduce the heart rate,
is 65 beats per minute. What action so the medication should be administered (C) because
should the nurse the client's apical pulse is greater than 60.
implement (A, B, and D) are not indicated at this time.
next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication.
4. 3.The nurse is assessing a client Hyperthyroidism
and identifies a bruit over the thy- Rationale:Hyperthyroidism (D) is an enlargement of the
roid. This finding is consistent thyroid gland, often referred to as a goiter, and a
with which interpretation? bruit may be auscultated over the goiter due to an
A. Hypothyroidism. increase in glandular vascularity which
B. Thyroid cyst. increases as the thyroid gland becomes hyperactive. A
C. Thyroid cancer. bruit is not common with (A, B, and C).
D. Hyperthyroidism
5. A 6-year-old child is alert but qui- Rhinorrhoea or otorrhoea with Halo sign.
et when brought to the emergency RATIONALE:
center with periorbital ecchymosis Raccoon eyes (periorbital ecchymosis) and Battle's sign
and ecchymosis behind the ears. (ecchymosis behind the ear over the
The nurse suspects potential child mastoid process) are both signs of a basilar skull frac-
abuse and continues to assess the ture, so the nurse should assess for possible
child for additional manifestations meningeal tears that manifest as a Halo sign with CSF
, HESI Critical Care Exam
Study online at https://quizlet.com/_c8s6s8
of a basilar skull fracture. What leakage from the ears or nose (D). (A) is
assessment finding would be con- consistent with orbital fractures. (B) occurs with
sistent with a basilar skull frac- wrenching traumas of the shoulder or arm
ture? fractures. (C) occurs with blunt abdominal injuries.
A. Hematemesis and abdominal
distention.
B. Asymmetry of the face and eye
movements.
C. Rhinorrhoea or otorrhoea with
Halo sign.
D. Abnormal position and move-
ment of the arm.
6. The nurse is assessing a client who Grave's disease
complains of weight loss, racing RATIONALE:
heart rate, and difficulty This client is exhibiting symptoms associated with hy-
sleeping. The nurse determines perthyroidism or Grave's disease (A),
the client has moist skin with fine which is an autoimmune condition affecting the thy-
hair, prominent eyes, lid roid. (B, C, and D) are not associated with
retraction, and a staring expres- these symptoms.
sion. These findings are consistent
with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome.
7. The nurse is assessing an old- Ptosis on the left eyelid
er client and determines that the Rationale: Ptosis is the term to describe an eyelid droop
client's left upper eyelid droops, that covers a large portion of the iris (A), which
covering more of the iris than may result from oculomotor nerve or eyelid muscle
the right eyelid. Which description disorder. (B) is characterized by rapid,
, HESI Critical Care Exam
Study online at https://quizlet.com/_c8s6s8
should the nurse use to rhythmic movement of both eyes. (C) is a distortion of
document this finding? the lens of the eye, causing decreased
A. A nystagmus on the left. visual acuity. (D) is a term used to describe a protrusion
B. Exophthalmos on the right. of the eyeballs that occurs with
C. Ptosis on the left eyelid. hyperthyroidism.
D. Astigmatism on the right.
8. The nurse is assessing a child's A. Question the type and quantity of foods eaten in a
weight and height during a clinic typical day.
visit prior to starting school. RATIONALE:
The nurse plots the child's weight The child is overweight for height, so assessment of the
on the growth chart and notes that child's daily diet (C) should be
the child's weight is in the determined. The child does not need (A or B), both of
95th percentile for the child's which will increase the child's weight.
height. What action should the Poor nutrition (D) is commonly seen in underweight
nurse take? children, not overweight.
A. Question the type and quantity
of foods eaten in a typical day.
B. Encourage giving two additional
snacks each day to the child.
C. Recommend a daily intake of at
least four glasses of whole milk.
D. Assess for signs of poor nutri-
tion, such as a pale appearance
9. A child is receiving maintenance in- B. 61
travenous (IV) fluids at the rate of RATIONALE:
1000 mL for the first 10 The formula for calculating daily fluid requirements is:
kg of body weight, plus 50 mL/kg 0 to 10 kg, 100 mL/kg per day; or 10 to
per day for each kilogram between 20 kg, 1000 mL for the first 10 kg of body weight plus
10 and 20. How many 50 mL/kg per day for each kilogram
milliliters per hour should the between 10 and 20. To determine an hourly rate, divide
