Critical Care Exit Hesi questions with |!| |!| |!| |!| |!| |!|
accurate detailed solutions |!| |!|
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. - correct answer✔✔1 |!| |!| |!|
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 - correct answer✔✔2
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
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?" - correct answer✔✔3
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
,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. - correct answer✔✔4
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
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 - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔3
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.
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2. Serum hematocrit 52%.
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3. Oral fluid intake of 900 mL in 24 hours.
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4. Blood pressure of 100/82. - correct answer✔✔1
|!| |!| |!| |!| |!| |!| |!|
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. - correct answer✔✔2
|!| |!| |!| |!| |!| |!| |!| |!| |!|
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."
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3. "I drove to the library yesterday."
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4. "I drink with a straw." - correct answer✔✔3
|!| |!| |!| |!| |!| |!| |!| |!|
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." - correct answer✔✔1
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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.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
- correct answer✔✔1
|!| |!| |!|
accurate detailed solutions |!| |!|
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. - correct answer✔✔1 |!| |!| |!|
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 - correct answer✔✔2
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
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?" - correct answer✔✔3
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
,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. - correct answer✔✔4
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
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 - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔3
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. - correct answer✔✔1
|!| |!| |!| |!| |!| |!| |!|
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. - correct answer✔✔2
|!| |!| |!| |!| |!| |!| |!| |!| |!|
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." - correct answer✔✔3
|!| |!| |!| |!| |!| |!| |!| |!|
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." - correct answer✔✔1
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
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.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
- correct answer✔✔1
|!| |!| |!|
