HESI RN Critical Care Nursing Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2027 Q&A |
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1. A nurse is caring for a client who has developed septic shock.
Which assessment finding requires immediate intervention?
A. Temperature of 38.5°C (101.3°F)
B. Heart rate of 112 beats/min
C. Blood pressure of 82/48 mmHg
D. White blood cell count of 15,000/mm³
Answer: C. Blood pressure of 82/48 mmHg
Rationale: A blood pressure of 82/48 mmHg indicates severe
hypotension associated with septic shock and inadequate tissue
perfusion. Immediate interventions include fluid resuscitation,
vasopressors, and close hemodynamic monitoring. Fever, tachycardia,
and elevated white blood cell count are common findings in infection
but are not as immediately life-threatening as profound hypotension.
, 2. A client in the intensive care unit develops sudden chest pain,
dyspnea, and oxygen saturation of 84%. Which action should the
nurse take first?
A. Obtain a 12-lead electrocardiogram
B. Administer oxygen therapy
C. Prepare the client for a chest CT scan
D. Notify the healthcare provider
Answer: B. Administer oxygen therapy
Rationale: The priority in critical care is to address airway and breathing
concerns first. The client is experiencing hypoxemia, so oxygen
administration should occur immediately. Diagnostic tests and provider
notification are important but should follow stabilization of
oxygenation.
3. A nurse is caring for a client receiving mechanical ventilation.
Which finding indicates the client may need suctioning?
A. Oxygen saturation of 98%
B. Clear bilateral breath sounds
,C. Coarse crackles and visible secretions
D. Respiratory rate of 16 breaths/min
Answer: C. Coarse crackles and visible secretions
Rationale: Coarse crackles and visible airway secretions indicate
retained secretions that may obstruct airflow and impair ventilation.
Suctioning may be required to maintain airway patency. Normal oxygen
saturation, clear breath sounds, and normal respiratory rate do not
indicate a need for suctioning.
4. A client with acute respiratory distress syndrome (ARDS) is
receiving mechanical ventilation. Which intervention is most
appropriate?
A. Administer large amounts of intravenous fluids
B. Use low tidal volume ventilation
C. Keep the client completely flat in bed
D. Discontinue oxygen therapy
Answer: B. Use low tidal volume ventilation
Rationale: Low tidal volume ventilation reduces the risk of additional
lung injury caused by mechanical ventilation in clients with ARDS.
, Excessive ventilation pressures can worsen alveolar damage. Fluid
overload and supine positioning can impair oxygenation.
5. A nurse is monitoring a client with increased intracranial pressure
(ICP). Which assessment finding requires immediate action?
A. Headache rated 4/10
B. Glasgow Coma Scale score decreasing from 14 to 10
C. Pupils equal and reactive to light
D. Mild nausea after medication administration
Answer: B. Glasgow Coma Scale score decreasing from 14 to 10
Rationale: A decreasing Glasgow Coma Scale score indicates worsening
neurological status and possible progression of intracranial pressure.
This requires immediate evaluation and intervention. Stable pupils and
mild symptoms are less concerning findings.
6. A client receiving a continuous heparin infusion has an activated
partial thromboplastin time (aPTT) that is significantly elevated.
What action should the nurse anticipate?
A. Increase the heparin infusion rate
B. Hold the infusion and notify the provider
Questions And Correct Answers (Verified
Answers) Plus Rationales 2027 Q&A |
Instant Download Pdf
1. A nurse is caring for a client who has developed septic shock.
Which assessment finding requires immediate intervention?
A. Temperature of 38.5°C (101.3°F)
B. Heart rate of 112 beats/min
C. Blood pressure of 82/48 mmHg
D. White blood cell count of 15,000/mm³
Answer: C. Blood pressure of 82/48 mmHg
Rationale: A blood pressure of 82/48 mmHg indicates severe
hypotension associated with septic shock and inadequate tissue
perfusion. Immediate interventions include fluid resuscitation,
vasopressors, and close hemodynamic monitoring. Fever, tachycardia,
and elevated white blood cell count are common findings in infection
but are not as immediately life-threatening as profound hypotension.
, 2. A client in the intensive care unit develops sudden chest pain,
dyspnea, and oxygen saturation of 84%. Which action should the
nurse take first?
A. Obtain a 12-lead electrocardiogram
B. Administer oxygen therapy
C. Prepare the client for a chest CT scan
D. Notify the healthcare provider
Answer: B. Administer oxygen therapy
Rationale: The priority in critical care is to address airway and breathing
concerns first. The client is experiencing hypoxemia, so oxygen
administration should occur immediately. Diagnostic tests and provider
notification are important but should follow stabilization of
oxygenation.
3. A nurse is caring for a client receiving mechanical ventilation.
Which finding indicates the client may need suctioning?
A. Oxygen saturation of 98%
B. Clear bilateral breath sounds
,C. Coarse crackles and visible secretions
D. Respiratory rate of 16 breaths/min
Answer: C. Coarse crackles and visible secretions
Rationale: Coarse crackles and visible airway secretions indicate
retained secretions that may obstruct airflow and impair ventilation.
Suctioning may be required to maintain airway patency. Normal oxygen
saturation, clear breath sounds, and normal respiratory rate do not
indicate a need for suctioning.
4. A client with acute respiratory distress syndrome (ARDS) is
receiving mechanical ventilation. Which intervention is most
appropriate?
A. Administer large amounts of intravenous fluids
B. Use low tidal volume ventilation
C. Keep the client completely flat in bed
D. Discontinue oxygen therapy
Answer: B. Use low tidal volume ventilation
Rationale: Low tidal volume ventilation reduces the risk of additional
lung injury caused by mechanical ventilation in clients with ARDS.
, Excessive ventilation pressures can worsen alveolar damage. Fluid
overload and supine positioning can impair oxygenation.
5. A nurse is monitoring a client with increased intracranial pressure
(ICP). Which assessment finding requires immediate action?
A. Headache rated 4/10
B. Glasgow Coma Scale score decreasing from 14 to 10
C. Pupils equal and reactive to light
D. Mild nausea after medication administration
Answer: B. Glasgow Coma Scale score decreasing from 14 to 10
Rationale: A decreasing Glasgow Coma Scale score indicates worsening
neurological status and possible progression of intracranial pressure.
This requires immediate evaluation and intervention. Stable pupils and
mild symptoms are less concerning findings.
6. A client receiving a continuous heparin infusion has an activated
partial thromboplastin time (aPTT) that is significantly elevated.
What action should the nurse anticipate?
A. Increase the heparin infusion rate
B. Hold the infusion and notify the provider
