2025 HESI RN CRITICAL CARE /CRITICAL CARE RN HESI
EXIT ACTUAL EXAM LATEST 200+ QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(100% VERIFIED ANSWERS) |LATEST VERSION!!!!
The nurses calculating fluid resuscitation for young adult male who
was burned in a bloody accident at 1200 and is seen in the ER at
1400. The HCP determines that the client has burn over 30% of his
body, mainly 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 clients plan of
care? - Answer -By 2000, the client will have received 3500 mL of
fluid
When caring for a client on a vent, which finding provides the
greatest indication that the client has an open airway? - Answer -
Bilateral breath sounds can be auscultated
The nurse performs a prescribed a neurological check at the beginning
of the shift on a client who was admitted with a subarachnoid brain
attack (Stroke). The client's GCS is 9. What information is most
important for the nurse to determine? - Answer -The client's previous
GCS score
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 DKA. Which
assessment finding warrants immediate intervention by the nurse? -
Answer -Excessive thirst
A client admitted to the ICU after a colon resection with the formation
of the loop colostomy. The nurse determines that the clients
abdominal dressing is clean and dry. Vital signs are: HR: 130,
temperature: 100, BP: 88/65, and urine output of 10 mL/hr. What
interventions should the nurse implement? - Answer -Give a 500 mL
IV fluid bolus challenge
A client is admitted with syncopal episodes related to a third degree
heart block. After the placement of a transcutaneous pacemaker, the
pg. 1
,nurse observes several episodes the pacemaker failure to sense. What
action should the nurse take? - Answer -Increase the sensitivity
A client is receiving CPR. After systole is confirmed in two leads and
sending the transcutaneous pacemaker, which IV medication should
be administered? - Answer -Epinephrine (adrenaline)
A client has a chest tube connected to a closed water seal drainage
system with suction. What equipment should the nurse always have
available at the clients bedside? - Answer -Occlusive dressing
Bretylium 1 mg/min via infusion is prescribed for a client and
ventricular tachycardia. The available solution is 500 mL D5W
contains bretylium 1 gram. The nurse should program the infusion
time to deliver how many mL/hr? - Answer -30
The client is receiving an infusion of nitroglycerin 100 mg and 500
mL D5W at 6 mL/hr. How many mcg/min of nitroglycerin is
infusing? - Answer -20
A client arrives in the ER complaining of pain. What description of
pain should prompt the nurse to suspect it originated in the
myocardium? - Answer -Produces chest heaviness with left arm pain
Four days ago a chest tube was inserted into the second intercostal
space of a client who has a pneumothorax. Today the nurse notes that
there is no fluctuation in the water-seal chamber of the Pleuravac.
Which intervention would be most appropriate for the nurse to
implement? - Answer -Assess the clients breath sounds of the affected
lung
In developing a care plan for a client that has a chest tube due to a
hemothorax, the nurse should recognize which intervention is
essential? - Answer -Encourage the client to breathe deeply and cough
at frequent intervals
A postoperative client is admitted the ICU with an inflated pressure
infuser containing solution of heparin 2 units/mL attached to an
intraarterial cannula. Which finding indicated that the heparin
pg. 2
,infusion has achieved its therapeutic use? - Answer -Intra-arterial
cannula remain patent
The nurse suspects that a client with a central venous catheter in the
left subclavian vein is experiencing an embolism. What signs and
symptoms are most indicative of this condition? - Answer -Anxiety,
confusion, lightheadedness, and loss consciousness
A female client has been in systole for 20 minutes. She is intubated,
and epinephrine (adrenaline) 1 mg and atropine sulfate 1 mg IV were
administered, with no change in rhythm. What intervention should the
nurse implement? - Answer -Bring members of the family to a private
area to discuss the desire to continue life saving efforts
The nurse is evaluating a clients central venous pressure reading that
are trending upwards. What nursing diagnosis is supported but the
pathophysiological mechanism most likely causing this increase? -
Answer -Impaired cardiac output
The high pressure alarm on a mechanical vent is alarming. What
intervention should the nurse implement immediately? - Answer -
Auscultate bilaterally for breath sounds and confirm endotracheal
suctioning
A client with a history of vasovagal attacks resulting in brady-
dysrhythmias. Which instruction is the most important in the teaching
plan? - Answer -Use stool softeners regularly
The ECG pattern of a client indicates that the cardiac rhythm has
changed from first degree to third degree AV block. What intervention
should the nurse implement? - Answer -Assess the clients BP
The nurse caring for a client who hemorrhaged postoperatively and is
in the early stage of shock. Which cardiopulmonary symptoms are
most indicative of progression into a state of shock? - Answer -
Increases pulse rate, lowered systolic pressure, peripheral extremity
mottling
pg. 3
, A 47-year-old female client is admitted to the cardiac ICU with an
acute MI, which occurred following a vigorous as a goal workout. She
tells the nurse, "I just had a little indigestion; I'll be fine a little while."
Which client problem has the highest priority? - Answer -Decreased
cardiac output
Which medication should the nurse anticipate administering to a
client in the ER who is experiencing a hypertensive crisis? - Answer -
Sodium nitroprusside (Nipride)
When initiating dopamine (intropin) infusion for a hypotensive client,
which intervention should the nurse include in the client's plan of
care? - Answer -Monitor urinary output every hour
Adult female with a history of chronic adrenal insufficiency is
admitted to the ICU for adrenal crisis. Which intervention should the
nurse implement first? - Answer -Give IV hydrocortisone
a female college student suffered second and third degree burns when
lighter fluid was tossed into the flames of a campfire. The burns
extended along the posterior surface of each arm from the deltoid
region to the hands and the interior surfaces of both legs from the
groin to ankles. According to the rule of nines, what percentage of the
clients body surface area is burned? - Answer -27%
Nursing care from a 58 year old female client with postoperative
complication include central venous pressure monitoring. What is the
most important consideration a in monitoring the CVP? - Answer -
The zero point on the manometer must be level with the right atrium
(4th intercostal space)
A male client is admitted to the cardiac ICU with chest pain that
began 12 hours ago. The nurse recognizes increased ventricular
ectopy. Based on this assessment finding, what action is most
important for the nurse to implement? - Answer -Initiate the units anti
arrhythmic protocol if symptomatic
A client is being treated for a MI that occurred less than 6 hours ago.
The cardiologist suspects 100% occlusion of the right coronary artery.
pg. 4
EXIT ACTUAL EXAM LATEST 200+ QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
(100% VERIFIED ANSWERS) |LATEST VERSION!!!!
The nurses calculating fluid resuscitation for young adult male who
was burned in a bloody accident at 1200 and is seen in the ER at
1400. The HCP determines that the client has burn over 30% of his
body, mainly 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 clients plan of
care? - Answer -By 2000, the client will have received 3500 mL of
fluid
When caring for a client on a vent, which finding provides the
greatest indication that the client has an open airway? - Answer -
Bilateral breath sounds can be auscultated
The nurse performs a prescribed a neurological check at the beginning
of the shift on a client who was admitted with a subarachnoid brain
attack (Stroke). The client's GCS is 9. What information is most
important for the nurse to determine? - Answer -The client's previous
GCS score
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 DKA. Which
assessment finding warrants immediate intervention by the nurse? -
Answer -Excessive thirst
A client admitted to the ICU after a colon resection with the formation
of the loop colostomy. The nurse determines that the clients
abdominal dressing is clean and dry. Vital signs are: HR: 130,
temperature: 100, BP: 88/65, and urine output of 10 mL/hr. What
interventions should the nurse implement? - Answer -Give a 500 mL
IV fluid bolus challenge
A client is admitted with syncopal episodes related to a third degree
heart block. After the placement of a transcutaneous pacemaker, the
pg. 1
,nurse observes several episodes the pacemaker failure to sense. What
action should the nurse take? - Answer -Increase the sensitivity
A client is receiving CPR. After systole is confirmed in two leads and
sending the transcutaneous pacemaker, which IV medication should
be administered? - Answer -Epinephrine (adrenaline)
A client has a chest tube connected to a closed water seal drainage
system with suction. What equipment should the nurse always have
available at the clients bedside? - Answer -Occlusive dressing
Bretylium 1 mg/min via infusion is prescribed for a client and
ventricular tachycardia. The available solution is 500 mL D5W
contains bretylium 1 gram. The nurse should program the infusion
time to deliver how many mL/hr? - Answer -30
The client is receiving an infusion of nitroglycerin 100 mg and 500
mL D5W at 6 mL/hr. How many mcg/min of nitroglycerin is
infusing? - Answer -20
A client arrives in the ER complaining of pain. What description of
pain should prompt the nurse to suspect it originated in the
myocardium? - Answer -Produces chest heaviness with left arm pain
Four days ago a chest tube was inserted into the second intercostal
space of a client who has a pneumothorax. Today the nurse notes that
there is no fluctuation in the water-seal chamber of the Pleuravac.
Which intervention would be most appropriate for the nurse to
implement? - Answer -Assess the clients breath sounds of the affected
lung
In developing a care plan for a client that has a chest tube due to a
hemothorax, the nurse should recognize which intervention is
essential? - Answer -Encourage the client to breathe deeply and cough
at frequent intervals
A postoperative client is admitted the ICU with an inflated pressure
infuser containing solution of heparin 2 units/mL attached to an
intraarterial cannula. Which finding indicated that the heparin
pg. 2
,infusion has achieved its therapeutic use? - Answer -Intra-arterial
cannula remain patent
The nurse suspects that a client with a central venous catheter in the
left subclavian vein is experiencing an embolism. What signs and
symptoms are most indicative of this condition? - Answer -Anxiety,
confusion, lightheadedness, and loss consciousness
A female client has been in systole for 20 minutes. She is intubated,
and epinephrine (adrenaline) 1 mg and atropine sulfate 1 mg IV were
administered, with no change in rhythm. What intervention should the
nurse implement? - Answer -Bring members of the family to a private
area to discuss the desire to continue life saving efforts
The nurse is evaluating a clients central venous pressure reading that
are trending upwards. What nursing diagnosis is supported but the
pathophysiological mechanism most likely causing this increase? -
Answer -Impaired cardiac output
The high pressure alarm on a mechanical vent is alarming. What
intervention should the nurse implement immediately? - Answer -
Auscultate bilaterally for breath sounds and confirm endotracheal
suctioning
A client with a history of vasovagal attacks resulting in brady-
dysrhythmias. Which instruction is the most important in the teaching
plan? - Answer -Use stool softeners regularly
The ECG pattern of a client indicates that the cardiac rhythm has
changed from first degree to third degree AV block. What intervention
should the nurse implement? - Answer -Assess the clients BP
The nurse caring for a client who hemorrhaged postoperatively and is
in the early stage of shock. Which cardiopulmonary symptoms are
most indicative of progression into a state of shock? - Answer -
Increases pulse rate, lowered systolic pressure, peripheral extremity
mottling
pg. 3
, A 47-year-old female client is admitted to the cardiac ICU with an
acute MI, which occurred following a vigorous as a goal workout. She
tells the nurse, "I just had a little indigestion; I'll be fine a little while."
Which client problem has the highest priority? - Answer -Decreased
cardiac output
Which medication should the nurse anticipate administering to a
client in the ER who is experiencing a hypertensive crisis? - Answer -
Sodium nitroprusside (Nipride)
When initiating dopamine (intropin) infusion for a hypotensive client,
which intervention should the nurse include in the client's plan of
care? - Answer -Monitor urinary output every hour
Adult female with a history of chronic adrenal insufficiency is
admitted to the ICU for adrenal crisis. Which intervention should the
nurse implement first? - Answer -Give IV hydrocortisone
a female college student suffered second and third degree burns when
lighter fluid was tossed into the flames of a campfire. The burns
extended along the posterior surface of each arm from the deltoid
region to the hands and the interior surfaces of both legs from the
groin to ankles. According to the rule of nines, what percentage of the
clients body surface area is burned? - Answer -27%
Nursing care from a 58 year old female client with postoperative
complication include central venous pressure monitoring. What is the
most important consideration a in monitoring the CVP? - Answer -
The zero point on the manometer must be level with the right atrium
(4th intercostal space)
A male client is admitted to the cardiac ICU with chest pain that
began 12 hours ago. The nurse recognizes increased ventricular
ectopy. Based on this assessment finding, what action is most
important for the nurse to implement? - Answer -Initiate the units anti
arrhythmic protocol if symptomatic
A client is being treated for a MI that occurred less than 6 hours ago.
The cardiologist suspects 100% occlusion of the right coronary artery.
pg. 4
