CRITICAL CARE HESI EXIT EXAM (V1) FINAL EXAM PACK | QUESTIONS AND
VERIFIED ANSWERS| 100% CORRECT| GRADE A+ |100% PASS
A female client presents in the emergency department and tells the nurse that she was raped last night.
Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department? - ANSWER A. Has she taken a bath since the rape
occurred?
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing
increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope - ANSWER B. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum
amylase. Which additional information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. - ANSWER A. Abdominal pain decreases when
lying supine
1 - ANSWER The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care,
the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST
appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
,3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.
2 - ANSWER A young adult brings a friend to the emergency department and states that the friend has
been using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date
3 - ANSWER The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?"
4 - ANSWER The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
determines that the client has pressed the button 11 times and received 6 doses of morphine during the
last hour. Which is the MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain.
3 - ANSWER A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is
MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
,4. Place the client supine with the foot of the bed elevated
1 - ANSWER A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration.
Which finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82.
2 - ANSWER The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
morning. Which medication should the nurse question giving to the client?
1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime.
3 - ANSWER The home care nurse visits a client with a halo fixator traction device. Which client
statement MOST concerns the nurse?
1. "My wife looks at the pin sites every day."
2. "I like to bathe in the tub."
3. "I drove to the library yesterday."
4. "I drink with a straw."
1 - ANSWER the nurse cares for a client diagnosed with depression. Which statement by the client
indicates improvement?
1. "I have been sleeping 6 hours at night."
2. "I have lost 2 lbs in the past week."
3. "Lately, I have trouble watching television."
4. "I have much less muscle tension now."
, 1 - ANSWER The nurse on the maternity unit must accept a transfer client from a medical/surgical unit.
The nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days.
4 - ANSWER The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST
important for the nurse to make which of these statements?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done.
4 - ANSWER The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and
incontinent of urine. What is the MOST important action for the nurse to take?
1. Insert an indwelling urinary drainage catheter.
2. Perform intermittent catheterization every 4 hours.
3. Offer the bedpan to the client every 2 hours.
4. Assist the client to a bedside commode every 2 hours.
2 - ANSWER The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned
to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is
480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be
administered. Which of the following is the FIRST action the nurse should take?
1. Check the client records to see if insulin was given prior to surgery.
2. Administer the 6 units of regular insulin subcutaneously.
3. Administer the insulin when oral fluids are tolerated.
4. Contact the healthcare provider.
VERIFIED ANSWERS| 100% CORRECT| GRADE A+ |100% PASS
A female client presents in the emergency department and tells the nurse that she was raped last night.
Which question is most important for the nurse to ask?
A. Has she taken a bath since the rape occurred?
B. Is the place where she lives a safe place?
C. Does she know the person who raped her?
D. Did she report the rape to the police department? - ANSWER A. Has she taken a bath since the rape
occurred?
The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial
meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing
increased intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope - ANSWER B. Sluggish and unequal pupillary responses
A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum
amylase. Which additional information is the client most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. - ANSWER A. Abdominal pain decreases when
lying supine
1 - ANSWER The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care,
the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST
appropriate action for the nurse to take?
1. Leave the cuff inflated and suction through the tracheostomy.
2. Deflate the cuff and suction through the tracheostomy tube.
,3. Inflate the cuff pressure to 40 mm Hg before suctioning.
4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.
2 - ANSWER A young adult brings a friend to the emergency department and states that the friend has
been using heroin. Which action by the nurse is the MOST appropriate?
1. Assess pupil size and reactivity.
2. Assess oxygen saturation levels.
3. Palpate dorsalis pedis pulses.
4. Ask the client if he knows today's date
3 - ANSWER The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask?
1. "Have you tried other methods to stop smoking?"
2. "How long have you been smoking?"
3. "Have you ever had chest pain?"
4. "Do you have a partial dental bridge?"
4 - ANSWER The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
determines that the client has pressed the button 11 times and received 6 doses of morphine during the
last hour. Which is the MOST appropriate action for the nurse to take?
1. Assess the patency of the PCA IV tubing.
2. Determine the client's understanding of the PCA pump function.
3. Obtain an order to begin a PCA infusion of fentanyl.
4. Ask the client to describe the pain.
3 - ANSWER A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is
MOST appropriate?
1. Place the client flat on her back.
2. Elevate the head of the bed 30 degrees.
3. Place the client on her left side with her legs flexed.
,4. Place the client supine with the foot of the bed elevated
1 - ANSWER A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration.
Which finding BEST indicates improving fluid status?
1. Urinary output of 1,500 mL in 24 hours.
2. Serum hematocrit 52%.
3. Oral fluid intake of 900 mL in 24 hours.
4. Blood pressure of 100/82.
2 - ANSWER The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the
morning. Which medication should the nurse question giving to the client?
1. 20 mg oral escitalopram (Celexa) in the morning.
2. 40 mg oral furosemide (Lasix) in the morning.
3. 300 mg of oral gabapentin (Neurontin) twice daily.
4. 10 mg zolpidem (Ambien) at bedtime.
3 - ANSWER The home care nurse visits a client with a halo fixator traction device. Which client
statement MOST concerns the nurse?
1. "My wife looks at the pin sites every day."
2. "I like to bathe in the tub."
3. "I drove to the library yesterday."
4. "I drink with a straw."
1 - ANSWER the nurse cares for a client diagnosed with depression. Which statement by the client
indicates improvement?
1. "I have been sleeping 6 hours at night."
2. "I have lost 2 lbs in the past week."
3. "Lately, I have trouble watching television."
4. "I have much less muscle tension now."
, 1 - ANSWER The nurse on the maternity unit must accept a transfer client from a medical/surgical unit.
The nurse considers which transfer client appropriate?
1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.
2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer.
3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg.
4. A 74-year-old client who has received intravenous antibiotics for 7 days.
4 - ANSWER The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST
important for the nurse to make which of these statements?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done.
4 - ANSWER The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and
incontinent of urine. What is the MOST important action for the nurse to take?
1. Insert an indwelling urinary drainage catheter.
2. Perform intermittent catheterization every 4 hours.
3. Offer the bedpan to the client every 2 hours.
4. Assist the client to a bedside commode every 2 hours.
2 - ANSWER The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned
to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is
480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be
administered. Which of the following is the FIRST action the nurse should take?
1. Check the client records to see if insulin was given prior to surgery.
2. Administer the 6 units of regular insulin subcutaneously.
3. Administer the insulin when oral fluids are tolerated.
4. Contact the healthcare provider.
