HESI CRITICAL THINKING RN NEWEST 2024 / CRITICAL CARE HESI E
n n n n n n n n n n
XIT ACTUAL EXAM TEST BANK 140 QUESTIONS AND CORRECT DE
n n n n n n n n n
TAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
n n n n n
|ALREADY GRADED A+||BRAND NEW!!
n n n
An56-year-
oldnfemale nclientnisnreceivingnintracavitarynradiationnviananradiumnimplant.nWhichnnursenshould
n be nassignedntoncare nfornthisnclient?
A. The nnurse nwhonisncaringnfornanothernclientnreceivingnintracavitarynradiation.
B. Annurse nwithnMarfan'snsyndrome nwhonisnpostmenopausal.
C. Annurse nwithnoncologynexperience nwhonmaynbe npregnant.
D. The nnurse nwhonisncaringnfornanothernclientnwhonhasnClostridiumndifficile.n-nanswer-
B.nAnnurse nwithnMarfan'snsyndrome nwhonisnpostmenopausal.
RATIONALE:
Anclientnreceivingnintracavitynradiationnposesnanradiationnhazardnasnlongnasnthenintracavitynradi
ationnsource nisninnplace.nAnnurse'snabilityntoncarenofnthisnclientnisnnotnaffectednbynMarfan'snsynd
rome n(B),nwhichnisnanhereditaryndisordernofnconnective ntissues,nbones,nmuscles,nligamentsnand
n skeletalnstructures.nThe ngoalnisntonlimitnanynone nstaff nmember'snexposure ntonthe ncalculated
time nspannbasednonnthe nhalf-
life nof nradium,nsuchnasnthennumbernof nminutesnatnthenbedside npernday,nson(A) nshouldnnotnbe nassign
ed.n(C) nshouldnnotnbenexposedntonthe nradiationnduentonthenpossible neffectnonnthenfetus.nAnradiationn
exposure ndecreasesnthenimmunenresponse ninnthenclientnwhonshouldnnotnbenexposedntonthenpotenti
alninadvertentntransmissionnofnanninfectiousnorganismn(D).
1.Anclientnwhonhasnactive ntuberculosisn(TB)nisnadmittedntonthenmedicalnunit.nWhatnactionnisnmostnim
portantnfornthe nnurse ntonimplement?
A. Fitnthe nclientnwithnanrespiratornmask.
B. Assignnthe nclientntonannegative nair-flownroom.
C. Donnancleanngownnfornclientncare.
D. Place nannisolationncartninnthe nhallwayn-nanswer-Assignnthe nclientntonannegative nair-flownroom
RATIONALE:
Active ntuberculosisnrequiresnimplementationnofnairborne nprecautions,nsonthe nclientnshouldnbe nassi
gnedntonannegative npressure nair-flownroomn(D).nAlthoughn(AnandnC) nshouldnbe nimplemented
,fornclientsninnisolationnwithncontactnprecautions,nitnisnmostnimportantnthatnairnflownfromnthe nroom
n isnminimizednwhennthenclientnhasnTB.n(B)nshouldnbenimplementednwhennthenclientnleavesnthenisol
ationnenvironment.
2.Anclientnisnreceivingnatenololn(Tenormin) n25nmgnPOnafternanmyocardialninfarction.nThennursendeter
minesnthe nclient'snapicalnpulsenisn65nbeatsnpernminute.nWhatnactionnshouldnthe nnurse nimplement
next?
A. Measure nthe nbloodnpressure.
B. Reassessnthe napicalnpulse.
C. Notifynthe nhealthcare nprovider.
D. Administernthe nmedication.n-nanswer-Administernthe nmedication
RATIONALE:
Atenolol,nanbeta-
blocker,nblocksnthe nbetanreceptorsnof nthensinoatrialnnodentonreducenthe nheartnrate,nsonthe nmedicati
onnshouldnbenadministeredn(C)nbecause nthenclient'snapicalnpulsenisngreaternthann60.n(A,nB,nandnD) nar
e nnotnindicatednatnthisntime.
3. The nnurse nisnassessingnanclientnandnidentifiesnanbruitnovernthe nthyroid.nThisnfindingnisnconsistent
n withnwhichninterpretation?
A. Hypothyroidism.
B. Thyroidncyst.
C. Thyroidncancer.
D. Hyperthyroidismn-nanswer-Hyperthyroidism
Rationale:Hyperthyroidismn(D) nisnannenlargementnofnthenthyroidngland,noftennreferredntonasnangoiter,nand
na
bruitnmaynbe nauscultatednovernthengoiternduentonannincreaseninnglandularnvascularitynwhichnincreas
esnasnthe nthyroidnglandnbecomesnhyperactive.nAnbruitnisnnotncommonnwithn(A,nB,nandnC).
,An6-year-
oldnchildnisnalertnbutnquietnwhennbroughtntonthe nemergencyncenternwithnperiorbitalnecchymosisnandnecch
ymosisnbehindnthenears.nThennurse nsuspectsnpotentialnchildnabuse nandncontinuesntonassessnthe nchildnforn
additionalnmanifestationsnof nanbasilarnskullnfracture.nWhat
assessmentnfindingnwouldnbe nconsistentnwithnanbasilarnskullnfracture?
A. Hematemesisnandnabdominalndistention.
B. Asymmetrynofnthe nface nandneye nmovements.
C. RhinorrhoeanornotorrhoeanwithnHalonsign.
D. Abnormalnpositionnandnmovementnof nthe narm.n-nanswer-RhinorrhoeanornotorrhoeanwithnHalonsign.
RATIONALE:
Raccoonneyesn(periorbitalnecchymosis)nandnBattle'snsignn(ecchymosisnbehindnthenearnovernthe nmast
oidnprocess) nare nbothnsignsnofnanbasilarnskullnfracture,nsonthennursenshouldnassessnfornpossible nmeni
ngealntearsnthatnmanifestnasnanHalonsignnwithnCSFnleakagenfromnthenearsnornnose n(D).n(A) nisnconsiste
ntnwithnorbitalnfractures.n(B) noccursnwithnwrenchingntraumasnofnthe nshouldernornarmnfractures.n(C)n
occursnwithnbluntnabdominalninjuries.
The nnurse nisnassessingnanclientnwhoncomplainsnofnweightnloss,nracingnheartnrate,nandndifficultynsleep
ing.nThe nnursendeterminesnthe nclientnhasnmoistnskinnwithnfinenhair,nprominentneyes,nlidnretraction,n
andnanstaringnexpression.nThese nfindingsnare nconsistentnwithnwhichndisorder?
A. Grave'sndisease.
B. Multiple nsclerosis.
C. Addison'sndisease.
D. Cushingnsyndrome.n-nanswer-Grave'sndisease
RATIONALE:
ThisnclientnisnexhibitingnsymptomsnassociatednwithnhyperthyroidismnornGrave'sndisease n(A),nw
hichnisnannautoimmune nconditionnaffectingnthenthyroid.n(B,nC,nandnD)narennotnassociatednwithnt
hese nsymptoms.
The nnurse nisnassessingnannoldernclientnandndeterminesnthatnthenclient'snleftnupperneyelidndroops,nco
veringnmore nof nthe nirisnthannthe nrightneyelid.nWhichndescriptionnshouldnthe nnurse nuse nto
, documentnthisnfinding?
A. Annystagmusnonnthe nleft.
B. Exophthalmosnonnthe nright.
C. Ptosisnonnthe nleftneyelid.
D. Astigmatismnonnthe nright.n-nanswer-Ptosisnonnthe nleftneyelid
Rationale:nPtosisnisnthe ntermntondescribe nanneyelidndroopnthatncoversnanlarge nportionnofnthe nirisn(A),nwhic
hnmaynresultnfromnoculomotornnerve norneyelidnmuscle ndisorder.n(B) nisncharacterizednbynrapid,
rhythmicnmovementnofnbothneyes.n(C) nisnandistortionnof nthenlensnofntheneye,ncausingndecreasedn
visualnacuity.n(D) nisnantermnusedntondescribe nanprotrusionnofntheneyeballsnthatnoccursnwithnhype
rthyroidism.
The nnurse nisnassessingnanchild'snweightnandnheightnduringnanclinicnvisitnpriorntonstartingnschool.nTh
e nnurse nplotsnthenchild'snweightnonnthengrowthnchartnandnnotesnthatnthenchild'snweightnisninnthen9
5thnpercentile nfornthe nchild'snheight.nWhatnactionnshouldnthe nnurse ntake?
A. Questionnthe ntype nandnquantitynof nfoodsneatenninnantypicalnday.
B. Encourage ngivingntwonadditionalnsnacksneachndayntonthe nchild.
C. Recommendnandailynintake nof natnleastnfournglassesnof nwhole nmilk.
D. Assessnfornsignsnofnpoornnutrition,nsuchnasnanpale nappearance n-nanswer-
A.nQuestionnthe ntype nandnquantitynof nfoodsneatenninnantypicalnday.
RATIONALE:
The nchildnisnoverweightnfornheight,nsonassessmentnofnthenchild'sndailyndietn(C) nshouldnbe ndeter
mined.nThe nchildndoesnnotnneedn(AnornB),nbothnofnwhichnwillnincrease nthe nchild'snweight.nPoorn
nutritionn(D) nisncommonlynseenninnunderweightnchildren,nnotnoverweight.
Anchildnisnreceivingnmaintenancenintravenousn(IV) nfluidsnatnthenrate nofn1000nmLnfornthe nfirstn10n
kgnof nbodynweight,nplusn50nmL/kgnperndaynforneachnkilogramnbetweenn10nandn20.nHownmany
millilitersnpernhournshouldnthennursenprogramntheninfusionnpumpnfornanchildnwhonweighsn19.5nkg?n(
Enternnumericnvalue nonly.nIfnroundingnisnrequired,nroundntonthe nnearestnwhole nnumber.)
A. 24
n n n n n n n n n n
XIT ACTUAL EXAM TEST BANK 140 QUESTIONS AND CORRECT DE
n n n n n n n n n
TAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
n n n n n
|ALREADY GRADED A+||BRAND NEW!!
n n n
An56-year-
oldnfemale nclientnisnreceivingnintracavitarynradiationnviananradiumnimplant.nWhichnnursenshould
n be nassignedntoncare nfornthisnclient?
A. The nnurse nwhonisncaringnfornanothernclientnreceivingnintracavitarynradiation.
B. Annurse nwithnMarfan'snsyndrome nwhonisnpostmenopausal.
C. Annurse nwithnoncologynexperience nwhonmaynbe npregnant.
D. The nnurse nwhonisncaringnfornanothernclientnwhonhasnClostridiumndifficile.n-nanswer-
B.nAnnurse nwithnMarfan'snsyndrome nwhonisnpostmenopausal.
RATIONALE:
Anclientnreceivingnintracavitynradiationnposesnanradiationnhazardnasnlongnasnthenintracavitynradi
ationnsource nisninnplace.nAnnurse'snabilityntoncarenofnthisnclientnisnnotnaffectednbynMarfan'snsynd
rome n(B),nwhichnisnanhereditaryndisordernofnconnective ntissues,nbones,nmuscles,nligamentsnand
n skeletalnstructures.nThe ngoalnisntonlimitnanynone nstaff nmember'snexposure ntonthe ncalculated
time nspannbasednonnthe nhalf-
life nof nradium,nsuchnasnthennumbernof nminutesnatnthenbedside npernday,nson(A) nshouldnnotnbe nassign
ed.n(C) nshouldnnotnbenexposedntonthe nradiationnduentonthenpossible neffectnonnthenfetus.nAnradiationn
exposure ndecreasesnthenimmunenresponse ninnthenclientnwhonshouldnnotnbenexposedntonthenpotenti
alninadvertentntransmissionnofnanninfectiousnorganismn(D).
1.Anclientnwhonhasnactive ntuberculosisn(TB)nisnadmittedntonthenmedicalnunit.nWhatnactionnisnmostnim
portantnfornthe nnurse ntonimplement?
A. Fitnthe nclientnwithnanrespiratornmask.
B. Assignnthe nclientntonannegative nair-flownroom.
C. Donnancleanngownnfornclientncare.
D. Place nannisolationncartninnthe nhallwayn-nanswer-Assignnthe nclientntonannegative nair-flownroom
RATIONALE:
Active ntuberculosisnrequiresnimplementationnofnairborne nprecautions,nsonthe nclientnshouldnbe nassi
gnedntonannegative npressure nair-flownroomn(D).nAlthoughn(AnandnC) nshouldnbe nimplemented
,fornclientsninnisolationnwithncontactnprecautions,nitnisnmostnimportantnthatnairnflownfromnthe nroom
n isnminimizednwhennthenclientnhasnTB.n(B)nshouldnbenimplementednwhennthenclientnleavesnthenisol
ationnenvironment.
2.Anclientnisnreceivingnatenololn(Tenormin) n25nmgnPOnafternanmyocardialninfarction.nThennursendeter
minesnthe nclient'snapicalnpulsenisn65nbeatsnpernminute.nWhatnactionnshouldnthe nnurse nimplement
next?
A. Measure nthe nbloodnpressure.
B. Reassessnthe napicalnpulse.
C. Notifynthe nhealthcare nprovider.
D. Administernthe nmedication.n-nanswer-Administernthe nmedication
RATIONALE:
Atenolol,nanbeta-
blocker,nblocksnthe nbetanreceptorsnof nthensinoatrialnnodentonreducenthe nheartnrate,nsonthe nmedicati
onnshouldnbenadministeredn(C)nbecause nthenclient'snapicalnpulsenisngreaternthann60.n(A,nB,nandnD) nar
e nnotnindicatednatnthisntime.
3. The nnurse nisnassessingnanclientnandnidentifiesnanbruitnovernthe nthyroid.nThisnfindingnisnconsistent
n withnwhichninterpretation?
A. Hypothyroidism.
B. Thyroidncyst.
C. Thyroidncancer.
D. Hyperthyroidismn-nanswer-Hyperthyroidism
Rationale:Hyperthyroidismn(D) nisnannenlargementnofnthenthyroidngland,noftennreferredntonasnangoiter,nand
na
bruitnmaynbe nauscultatednovernthengoiternduentonannincreaseninnglandularnvascularitynwhichnincreas
esnasnthe nthyroidnglandnbecomesnhyperactive.nAnbruitnisnnotncommonnwithn(A,nB,nandnC).
,An6-year-
oldnchildnisnalertnbutnquietnwhennbroughtntonthe nemergencyncenternwithnperiorbitalnecchymosisnandnecch
ymosisnbehindnthenears.nThennurse nsuspectsnpotentialnchildnabuse nandncontinuesntonassessnthe nchildnforn
additionalnmanifestationsnof nanbasilarnskullnfracture.nWhat
assessmentnfindingnwouldnbe nconsistentnwithnanbasilarnskullnfracture?
A. Hematemesisnandnabdominalndistention.
B. Asymmetrynofnthe nface nandneye nmovements.
C. RhinorrhoeanornotorrhoeanwithnHalonsign.
D. Abnormalnpositionnandnmovementnof nthe narm.n-nanswer-RhinorrhoeanornotorrhoeanwithnHalonsign.
RATIONALE:
Raccoonneyesn(periorbitalnecchymosis)nandnBattle'snsignn(ecchymosisnbehindnthenearnovernthe nmast
oidnprocess) nare nbothnsignsnofnanbasilarnskullnfracture,nsonthennursenshouldnassessnfornpossible nmeni
ngealntearsnthatnmanifestnasnanHalonsignnwithnCSFnleakagenfromnthenearsnornnose n(D).n(A) nisnconsiste
ntnwithnorbitalnfractures.n(B) noccursnwithnwrenchingntraumasnofnthe nshouldernornarmnfractures.n(C)n
occursnwithnbluntnabdominalninjuries.
The nnurse nisnassessingnanclientnwhoncomplainsnofnweightnloss,nracingnheartnrate,nandndifficultynsleep
ing.nThe nnursendeterminesnthe nclientnhasnmoistnskinnwithnfinenhair,nprominentneyes,nlidnretraction,n
andnanstaringnexpression.nThese nfindingsnare nconsistentnwithnwhichndisorder?
A. Grave'sndisease.
B. Multiple nsclerosis.
C. Addison'sndisease.
D. Cushingnsyndrome.n-nanswer-Grave'sndisease
RATIONALE:
ThisnclientnisnexhibitingnsymptomsnassociatednwithnhyperthyroidismnornGrave'sndisease n(A),nw
hichnisnannautoimmune nconditionnaffectingnthenthyroid.n(B,nC,nandnD)narennotnassociatednwithnt
hese nsymptoms.
The nnurse nisnassessingnannoldernclientnandndeterminesnthatnthenclient'snleftnupperneyelidndroops,nco
veringnmore nof nthe nirisnthannthe nrightneyelid.nWhichndescriptionnshouldnthe nnurse nuse nto
, documentnthisnfinding?
A. Annystagmusnonnthe nleft.
B. Exophthalmosnonnthe nright.
C. Ptosisnonnthe nleftneyelid.
D. Astigmatismnonnthe nright.n-nanswer-Ptosisnonnthe nleftneyelid
Rationale:nPtosisnisnthe ntermntondescribe nanneyelidndroopnthatncoversnanlarge nportionnofnthe nirisn(A),nwhic
hnmaynresultnfromnoculomotornnerve norneyelidnmuscle ndisorder.n(B) nisncharacterizednbynrapid,
rhythmicnmovementnofnbothneyes.n(C) nisnandistortionnof nthenlensnofntheneye,ncausingndecreasedn
visualnacuity.n(D) nisnantermnusedntondescribe nanprotrusionnofntheneyeballsnthatnoccursnwithnhype
rthyroidism.
The nnurse nisnassessingnanchild'snweightnandnheightnduringnanclinicnvisitnpriorntonstartingnschool.nTh
e nnurse nplotsnthenchild'snweightnonnthengrowthnchartnandnnotesnthatnthenchild'snweightnisninnthen9
5thnpercentile nfornthe nchild'snheight.nWhatnactionnshouldnthe nnurse ntake?
A. Questionnthe ntype nandnquantitynof nfoodsneatenninnantypicalnday.
B. Encourage ngivingntwonadditionalnsnacksneachndayntonthe nchild.
C. Recommendnandailynintake nof natnleastnfournglassesnof nwhole nmilk.
D. Assessnfornsignsnofnpoornnutrition,nsuchnasnanpale nappearance n-nanswer-
A.nQuestionnthe ntype nandnquantitynof nfoodsneatenninnantypicalnday.
RATIONALE:
The nchildnisnoverweightnfornheight,nsonassessmentnofnthenchild'sndailyndietn(C) nshouldnbe ndeter
mined.nThe nchildndoesnnotnneedn(AnornB),nbothnofnwhichnwillnincrease nthe nchild'snweight.nPoorn
nutritionn(D) nisncommonlynseenninnunderweightnchildren,nnotnoverweight.
Anchildnisnreceivingnmaintenancenintravenousn(IV) nfluidsnatnthenrate nofn1000nmLnfornthe nfirstn10n
kgnof nbodynweight,nplusn50nmL/kgnperndaynforneachnkilogramnbetweenn10nandn20.nHownmany
millilitersnpernhournshouldnthennursenprogramntheninfusionnpumpnfornanchildnwhonweighsn19.5nkg?n(
Enternnumericnvalue nonly.nIfnroundingnisnrequired,nroundntonthe nnearestnwhole nnumber.)
A. 24
