Hesi exit critical care Exam questions with |!| |!| |!| |!| |!| |!| |!|
verified solutions & rationales |!| |!| |!|
The nurse is caring for a client who presents with stroke-like symptoms. The healthcare
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
provider reviews the client's computerized axial tomography (CAT) scan and prescribes
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
recombinant tissue plasminogen activator (rtPA) IV. Which information should the nurse |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
obtain to determine if the client is a candidate for this treatment now?
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
A.) Identify the underlying cause of this condition.
|!| |!| |!| |!| |!| |!| |!|
B.) Prepare to administer desmopressin (DDAVP).
|!| |!| |!| |!| |!|
C.) Decrease the intravenous fluids to a maintenance rate.
|!| |!| |!| |!| |!| |!| |!| |!|
D.) Replace fluid losses with D5W every shift
|!| |!| |!| |!| |!| |!| |!|
B.) Prepare to administer desmopressin (DDAVP).
|!| |!| |!| |!| |!|
Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma to
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the brain such as tumors or injury to the brain in particular the pituitary or
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
hypothalamus area. DI can also occur with cerebral edema present. The antidiuretic |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
hormone deficiency occurs rapidly and results in polyuria, anywhere between 5- 40
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
liters of urine/24 hours. The client demonstrates signs and symptoms of hypovolemia.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Electrolyte imbalances include hypernatremia, along with hypokalemia and|!| |!| |!| |!| |!| |!| |!| |!|
hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are primarily |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
controlled through administration of exogenous ADH preparations, of which
|!| |!| |!| |!| |!| |!| |!| |!| |!|
desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored and |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
fluids are replaced every hour.
|!| |!| |!| |!|
An intubated client is in the process of being weaned off ventilator support. The client's
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
baseline parameters are temperature 98.2 F (36.8 C), heart rate 88 beats/minute,
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
respirations 14 breaths/minute, blood pressure 112/78 mmHg, and oxygen saturation |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
94%. Which assessment findings would indicate to the nurse that the client is tolerating
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the weaning procedure? (Select all that apply.)
|!| |!| |!| |!| |!| |!|
A.) Oxygen saturation is 91%
|!| |!| |!| |!|
B.) Slight nasal flaring is present.
|!| |!| |!| |!| |!|
C.) Heart rate is 97 beats/minute.
|!| |!| |!| |!| |!|
D.) Work of breathing is done by client
|!| |!| |!| |!| |!| |!| |!|
E.) Respiratory rate is 36 breaths/minute.
|!| |!| |!| |!| |!|
,A.) Oxygen saturation is 91%
|!| |!| |!| |!|
C.) Heart rate is 97 beats/minute.
|!| |!| |!| |!| |!|
D.) Work of breathing is done by client
|!| |!| |!| |!| |!| |!| |!|
Criteria that indicates a client is tolerating weaning off ventilator support are
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
respirations greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
saturation above 90%; heart rate that does not increase more than 20% from baseline
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
heart rate; most of the work of breathing is performed by the client; and no signs of
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
accessory muscles are used for breathing. |!| |!| |!| |!| |!|
The nurse is assessing a burn victim who suffered destruction of the epidermis and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
some of the dermis of the entire right arm and half the length of the right leg. How
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
should the nurse document the burn assessment findings?
|!| |!| |!| |!| |!| |!| |!|
A.) Superficial, 18% TBSA.
|!| |!| |!|
B.) Superficial partial-thickness, 18% TBSA.
|!| |!| |!| |!|
C.) Deep-partial thickness, 27% TBSA.
|!| |!| |!| |!|
D.) Full-thickness, 27% TBSA.
|!| |!| |!|
B.) Superficial partial-thickness, 18% TBSA
|!| |!| |!| |!|
A "superficial partial-thickness" burn involves destruction of the epidermis layer and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
some of the dermis layer. The total body surface area (%TBSA) is easily calculated by
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
using the "rule of nines" method. In this case, involvement of one arm is calculated as
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
9% TBSA and one-half of a leg is 9% TBSA for a combined total of 18% TBSA. A total leg
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
involvement is calculated as 18% TBSA.
|!| |!| |!| |!| |!| |!|
he critical care nurse is providing care for a client diagnosed clinically brain dead and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
identified as an organ donor. Which are the nurse's priorities in providing care? (Select
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
all that apply.)
|!| |!|
A.) Sustaining a state of hypothermia.
|!| |!| |!| |!| |!|
B.) Maintaining a normal blood pressure.
|!| |!| |!| |!| |!|
C.) Ensuring adequate oxygenation and ventilation.
|!| |!| |!| |!| |!|
D.) Treating any coagulopathy, thrombocytopenia and anemia.
|!| |!| |!| |!| |!| |!|
E.) Monitoring arterial blood gases and serum electrolytes levels.
|!| |!| |!| |!| |!| |!| |!| |!|
B.) Maintaining a normal blood pressure.
|!| |!| |!| |!| |!|
C.) Ensuring adequate oxygenation and ventilation.
|!| |!| |!| |!| |!|
D.) Treating any coagulopathy, thrombocytopenia and anemia.
|!| |!| |!| |!| |!| |!|
E.) Monitoring arterial blood gases and serum electrolytes levels.
|!| |!| |!| |!| |!| |!| |!| |!|
Once an identified organ donor has been declared clinically brain dead, the primary
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
, focus of care changes from preserving life to preserving organ functioning. This is done
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
by maintaining normal blood pressures, fluid levels, electrolytes levels, serum glucose
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
levels, and normothermia. Mechanical ventilation is provided to maintain adequate
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
oxygenation and normal acid-base balance. If needed, pharmaceutical support is |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
provided for the treatment of anemia, coagulopathy, thrombocytopenia, and diabetes
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
insipidus. Physiological changes occur to bodily functions as the result of decreased
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
perfusion within the brain. |!| |!| |!|
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.
|!| |!|
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 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.
|!| |!|
A.) Contrast-enhanced computed tomography (CT)
|!| |!| |!| |!|
Contrast-enhanced computed tomography (CT) is the imaging modality of choice to |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
evaluate peripancreatic necrosis. |!| |!|
We have an expert-written solution to this problem!
|!| |!| |!| |!| |!| |!| |!|
verified solutions & rationales |!| |!| |!|
The nurse is caring for a client who presents with stroke-like symptoms. The healthcare
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
provider reviews the client's computerized axial tomography (CAT) scan and prescribes
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
recombinant tissue plasminogen activator (rtPA) IV. Which information should the nurse |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
obtain to determine if the client is a candidate for this treatment now?
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
A.) Identify the underlying cause of this condition.
|!| |!| |!| |!| |!| |!| |!|
B.) Prepare to administer desmopressin (DDAVP).
|!| |!| |!| |!| |!|
C.) Decrease the intravenous fluids to a maintenance rate.
|!| |!| |!| |!| |!| |!| |!| |!|
D.) Replace fluid losses with D5W every shift
|!| |!| |!| |!| |!| |!| |!|
B.) Prepare to administer desmopressin (DDAVP).
|!| |!| |!| |!| |!|
Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma to
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the brain such as tumors or injury to the brain in particular the pituitary or
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
hypothalamus area. DI can also occur with cerebral edema present. The antidiuretic |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
hormone deficiency occurs rapidly and results in polyuria, anywhere between 5- 40
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
liters of urine/24 hours. The client demonstrates signs and symptoms of hypovolemia.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Electrolyte imbalances include hypernatremia, along with hypokalemia and|!| |!| |!| |!| |!| |!| |!| |!|
hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are primarily |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
controlled through administration of exogenous ADH preparations, of which
|!| |!| |!| |!| |!| |!| |!| |!| |!|
desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored and |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
fluids are replaced every hour.
|!| |!| |!| |!|
An intubated client is in the process of being weaned off ventilator support. The client's
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
baseline parameters are temperature 98.2 F (36.8 C), heart rate 88 beats/minute,
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
respirations 14 breaths/minute, blood pressure 112/78 mmHg, and oxygen saturation |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
94%. Which assessment findings would indicate to the nurse that the client is tolerating
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the weaning procedure? (Select all that apply.)
|!| |!| |!| |!| |!| |!|
A.) Oxygen saturation is 91%
|!| |!| |!| |!|
B.) Slight nasal flaring is present.
|!| |!| |!| |!| |!|
C.) Heart rate is 97 beats/minute.
|!| |!| |!| |!| |!|
D.) Work of breathing is done by client
|!| |!| |!| |!| |!| |!| |!|
E.) Respiratory rate is 36 breaths/minute.
|!| |!| |!| |!| |!|
,A.) Oxygen saturation is 91%
|!| |!| |!| |!|
C.) Heart rate is 97 beats/minute.
|!| |!| |!| |!| |!|
D.) Work of breathing is done by client
|!| |!| |!| |!| |!| |!| |!|
Criteria that indicates a client is tolerating weaning off ventilator support are
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
respirations greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
saturation above 90%; heart rate that does not increase more than 20% from baseline
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
heart rate; most of the work of breathing is performed by the client; and no signs of
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
accessory muscles are used for breathing. |!| |!| |!| |!| |!|
The nurse is assessing a burn victim who suffered destruction of the epidermis and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
some of the dermis of the entire right arm and half the length of the right leg. How
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
should the nurse document the burn assessment findings?
|!| |!| |!| |!| |!| |!| |!|
A.) Superficial, 18% TBSA.
|!| |!| |!|
B.) Superficial partial-thickness, 18% TBSA.
|!| |!| |!| |!|
C.) Deep-partial thickness, 27% TBSA.
|!| |!| |!| |!|
D.) Full-thickness, 27% TBSA.
|!| |!| |!|
B.) Superficial partial-thickness, 18% TBSA
|!| |!| |!| |!|
A "superficial partial-thickness" burn involves destruction of the epidermis layer and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
some of the dermis layer. The total body surface area (%TBSA) is easily calculated by
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
using the "rule of nines" method. In this case, involvement of one arm is calculated as
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
9% TBSA and one-half of a leg is 9% TBSA for a combined total of 18% TBSA. A total leg
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
involvement is calculated as 18% TBSA.
|!| |!| |!| |!| |!| |!|
he critical care nurse is providing care for a client diagnosed clinically brain dead and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
identified as an organ donor. Which are the nurse's priorities in providing care? (Select
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
all that apply.)
|!| |!|
A.) Sustaining a state of hypothermia.
|!| |!| |!| |!| |!|
B.) Maintaining a normal blood pressure.
|!| |!| |!| |!| |!|
C.) Ensuring adequate oxygenation and ventilation.
|!| |!| |!| |!| |!|
D.) Treating any coagulopathy, thrombocytopenia and anemia.
|!| |!| |!| |!| |!| |!|
E.) Monitoring arterial blood gases and serum electrolytes levels.
|!| |!| |!| |!| |!| |!| |!| |!|
B.) Maintaining a normal blood pressure.
|!| |!| |!| |!| |!|
C.) Ensuring adequate oxygenation and ventilation.
|!| |!| |!| |!| |!|
D.) Treating any coagulopathy, thrombocytopenia and anemia.
|!| |!| |!| |!| |!| |!|
E.) Monitoring arterial blood gases and serum electrolytes levels.
|!| |!| |!| |!| |!| |!| |!| |!|
Once an identified organ donor has been declared clinically brain dead, the primary
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
, focus of care changes from preserving life to preserving organ functioning. This is done
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
by maintaining normal blood pressures, fluid levels, electrolytes levels, serum glucose
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
levels, and normothermia. Mechanical ventilation is provided to maintain adequate
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
oxygenation and normal acid-base balance. If needed, pharmaceutical support is |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
provided for the treatment of anemia, coagulopathy, thrombocytopenia, and diabetes
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
insipidus. Physiological changes occur to bodily functions as the result of decreased
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
perfusion within the brain. |!| |!| |!|
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.
|!| |!|
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 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.
|!| |!|
A.) Contrast-enhanced computed tomography (CT)
|!| |!| |!| |!|
Contrast-enhanced computed tomography (CT) is the imaging modality of choice to |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
evaluate peripancreatic necrosis. |!| |!|
We have an expert-written solution to this problem!
|!| |!| |!| |!| |!| |!| |!|
