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HESI RN CRITICAL CARE ACTUAL VERIFIED
QUESTIONS AND CORRECT DETAILED ANSWERS
LATEST UPDATE.pdf
A client is admitted to the intensive care unit with
hematemesis related to esophageal varices. Which
assessment finding should the nurse identify that is the
result of an estimated blood loss at 35% of total blood
volume?
A.) Absent bowel sounds.
B.) Coma.
C.) Anuria.
D.) Abdominal pain. - Answer-A.) Absent bowel sounds.
Massive blood loss redirects a significant amount of blood
flow to vital organs. A client who has lost 30% to 40% of
the total blood volume will exhibit absent bowel sounds,
lethargy, and increased serum potassium.
The nurse is planning care for a client admitted to the
intensive care unit with acute infected necrotizing
pancreatitis. Which diagnostic procedure should the nurse
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prepare the client to expect the healthcare provider to
prescribe?
A.) Contrast-enhanced computed tomography (CT).
B.) Endoscopic retrograde cholangiopancreatography
(ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound. - Answer-A.) Contrast-
enhanced computed tomography (CT)
Contrast-enhanced computed tomography (CT) is the
imaging modality of choice to evaluate peripancreatic
necrosis.
The nurse is caring for a client admitted to the surgical
intensive care unit (ICU) after undergoing gastrointestinal
surgery. Which intervention should the nurse include in the
plan of care to minimize the risk for vomiting?
A.) Maintain patency of nasogastric tube to low intermittent
suction.
B.) Provide a soft, bland diet with oral liquids, such as
diluted juices.
C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR)
solution IV at 125 mL/hour.
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D.) Insert a rectal tube followed with progressive
mobilization techniques. - Answer-A.) Maintain patency of
nasogastric tube to low intermittent suction.
Gastrointestinal (GI) surgery often requires postoperative
nasogastric tube (NGT) insertion for low intermittent
suction to prevent intestinal blockage due to absent or
decreased peristalsis. The plan of care should include
maintaining patency of the NGT to low intermittent suction,
which empties the stomach and minimizes nausea and
vomiting.
A client is admitted to the intensive care unit with hepatic
encephalopathy secondary to cirrhosis. The client is
lethargic and confused. The healthcare provider
prescribes lactulose. Which finding indicates a positive
response to the medication?
A.) An increase in alertness and orientation.
B.) Serum ammonia level 80 mcg/dL (47 mol/L).
C.) Multiple diarrheal stools per day.
D.) Decreased jaundice of skin and sclera. - Answer-A.)
An increase in alertness and orientation.
Hepatic dysfunction causes an elevated ammonia levels
that cause mental status changes in clients with hepatic
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encephalopathy. Lactulose, an osmotic laxative and
colonic acidifier, pulls ammonia from the serum into the
gut to facilitate ammonia elimination. An improved mental
state indicates a positive response to lactulose.
The nurse is caring for a client who is admitted to the
critical care unit with a closed head injury sustained in a
motor vehicle collision. Which finding in the client's vital
sign flowsheet indicates an increase in intracranial
pressure?
A.) Heart rate 45 beats per minute and blood pressure
180/80 mm Hg.
B.) Heart rate 70 beats per minute and blood pressure
140/100 mm Hg.
C.) Heart rate 90 beats per minute and blood pressure
120/80 mm Hg.
D.) Heart rate 110 beats per minute and blood pressure
80/40 mm Hg - Answer-A.) Heart rate 45 beats per minute
and blood pressure 180/80 mm Hg.
A hallmark sign of increased intracranial pressure includes
a trending of heart rate and blood pressures changes to
bradycardia and systolic hypertension with a widening
pulse pressure, which is known as Cushing's triad. The
client is manifesting Cushing's triad with a heart rate of 45
HESI RN CRITICAL CARE ACTUAL VERIFIED
QUESTIONS AND CORRECT DETAILED ANSWERS
LATEST UPDATE.pdf
A client is admitted to the intensive care unit with
hematemesis related to esophageal varices. Which
assessment finding should the nurse identify that is the
result of an estimated blood loss at 35% of total blood
volume?
A.) Absent bowel sounds.
B.) Coma.
C.) Anuria.
D.) Abdominal pain. - Answer-A.) Absent bowel sounds.
Massive blood loss redirects a significant amount of blood
flow to vital organs. A client who has lost 30% to 40% of
the total blood volume will exhibit absent bowel sounds,
lethargy, and increased serum potassium.
The nurse is planning care for a client admitted to the
intensive care unit with acute infected necrotizing
pancreatitis. Which diagnostic procedure should the nurse
,2|Page
prepare the client to expect the healthcare provider to
prescribe?
A.) Contrast-enhanced computed tomography (CT).
B.) Endoscopic retrograde cholangiopancreatography
(ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound. - Answer-A.) Contrast-
enhanced computed tomography (CT)
Contrast-enhanced computed tomography (CT) is the
imaging modality of choice to evaluate peripancreatic
necrosis.
The nurse is caring for a client admitted to the surgical
intensive care unit (ICU) after undergoing gastrointestinal
surgery. Which intervention should the nurse include in the
plan of care to minimize the risk for vomiting?
A.) Maintain patency of nasogastric tube to low intermittent
suction.
B.) Provide a soft, bland diet with oral liquids, such as
diluted juices.
C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR)
solution IV at 125 mL/hour.
,3|Page
D.) Insert a rectal tube followed with progressive
mobilization techniques. - Answer-A.) Maintain patency of
nasogastric tube to low intermittent suction.
Gastrointestinal (GI) surgery often requires postoperative
nasogastric tube (NGT) insertion for low intermittent
suction to prevent intestinal blockage due to absent or
decreased peristalsis. The plan of care should include
maintaining patency of the NGT to low intermittent suction,
which empties the stomach and minimizes nausea and
vomiting.
A client is admitted to the intensive care unit with hepatic
encephalopathy secondary to cirrhosis. The client is
lethargic and confused. The healthcare provider
prescribes lactulose. Which finding indicates a positive
response to the medication?
A.) An increase in alertness and orientation.
B.) Serum ammonia level 80 mcg/dL (47 mol/L).
C.) Multiple diarrheal stools per day.
D.) Decreased jaundice of skin and sclera. - Answer-A.)
An increase in alertness and orientation.
Hepatic dysfunction causes an elevated ammonia levels
that cause mental status changes in clients with hepatic
, 4|Page
encephalopathy. Lactulose, an osmotic laxative and
colonic acidifier, pulls ammonia from the serum into the
gut to facilitate ammonia elimination. An improved mental
state indicates a positive response to lactulose.
The nurse is caring for a client who is admitted to the
critical care unit with a closed head injury sustained in a
motor vehicle collision. Which finding in the client's vital
sign flowsheet indicates an increase in intracranial
pressure?
A.) Heart rate 45 beats per minute and blood pressure
180/80 mm Hg.
B.) Heart rate 70 beats per minute and blood pressure
140/100 mm Hg.
C.) Heart rate 90 beats per minute and blood pressure
120/80 mm Hg.
D.) Heart rate 110 beats per minute and blood pressure
80/40 mm Hg - Answer-A.) Heart rate 45 beats per minute
and blood pressure 180/80 mm Hg.
A hallmark sign of increased intracranial pressure includes
a trending of heart rate and blood pressures changes to
bradycardia and systolic hypertension with a widening
pulse pressure, which is known as Cushing's triad. The
client is manifesting Cushing's triad with a heart rate of 45
