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HESI RN CRITICAL CARE 2023 AND 2024
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HESI RN CRITICAL CARE 2023 AND 2024
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HESI RN CRITICAL CARE 2023 AND 2024 /CRITICAL CARERN HESI EXIT ACTUAL EXAM TEST BANK LATEST
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A+
The triage nurse is assessing a victim of a stab wound. According to the paramedics,
the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in
length and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two
inches above and left of the victim's xiphoid process. Which vital organ(s) are at an
increased risk of being in the direct path of injury? - ANSWER: Heart
Lungs
Diaphragm
What way do females stab? - ANSWER: Downwards
What way do males stab? - ANSWER: Upwards
A client reports to the nurse feeling achy and weak, being tired and coughing all the
time, frequent headaches and experiencing night sweats. The client's assessment is
significant for crackles scattered throughout the lungs, dependent peripheral edema
+3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110
beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60
mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the
nurse prepare to do first? - ANSWER: Blood culture
Define: Infective endocarditis - ANSWER: Infection of the endocardial surface of the
heart, usually the heart valves
What indicates ineffective endocarditis? - ANSWER: Edema & S1/S3 sounds
According to the paramedic's report, the victim of a motor vehicle collision was
sitting in the passenger seat on the left side of the vehicle. The vehicle was stopped
at a traffic light when the vehicle was hit on the left side by another vehicle traveling
at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and
achiness on (L) side of thorax and body. The significant assessment findings include:
weak and thready pulse; diffuse abdominal pain, tenderness and guarding present
upon palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in
extremities, and bruising is present in the (L) flank area and progresses towards the
abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110 beats/minute,
respirations- 22 breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse
oximetry 90% on 2 lpm O2 via nasal cannula. - ANSWER: Fractured liver & ruptured
spleen
, The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly
ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter.
How should the nurse interpret this blood gas? - ANSWER: Respiratory alkalosis
Define: Respiratory alkalosis - ANSWER: HCO3 & pH is increased while the CO2 is
decreased
What is the effect if blood sugar continues to rise? - ANSWER: Change in level of
consciousness
What precaution should a patient be on with a high sodium? - ANSWER: Seizure
precautions
Why do people with diabetes have an increased urinary output? - ANSWER: Low
ADH
What is the effect of a low ADH? - ANSWER: Dehydration & increased serum Sodium
A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is
admitted to the intensive care unit with a serum sodium level of 112 mEq/L or
mmol/L. Which protocol prescription should the nurse implement first? - ANSWER:
Obtain serum sodium every 4 hours
The nurse is caring for a client who is demonstrating signs of impending death. The
family is experiencing emotional distress as the client's condition declines. Which
information should the nurse provide the family to facilitate the process? - ANSWER:
Encourage the family to give the patient permission to die
The nurse is caring for a client with severe sepsis related to a ruptured appendix.The
clientis diaphoretic and reports lower extremity spasms. The nurse observes
respirations that are uneven and labored. Arterial blood gas (ABG) results are pH
7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment
finding warrants immediate intervention by the nurse? - ANSWER: Intercostal muscle
contraction
Define: Intercostal muscle contraction - ANSWER: Critical sign of respiratory muscle
fatigue which is likely to lead to acute respiratory failure
Define: Cistacurium - ANSWER: Paralytic during surgery
A client who experienced an intracranial hemorrhage is receiving cistracurium to
induce a pharmacological state of paralysis. Which intervention should the nurse
implement during the therapeutic paralysis? - ANSWER: Administer a sedating
medication
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