2023 HESI RN CRITICAL CARE /CRITICAL CARE RN HESI
EXIT ACTUAL EXAM TEST BANK LATEST 350 QUESTIONS
AND CORRECT DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS) |ALREADY GRADED A+
A client is mechanically ventilated for respiratory failure and struggles to breathe.
The client has a respiratory rate of 32, heart rate of 126, and O2 saturation of 98%.
The nurse checks the circuit for leaks, assures the endotracheal tube is properly
placed, and notifies the healthcare provider about the client’s distress. Which
prescription should the nurse implement?
A.) Give sedation to allow the ventilator to adequately assist the client’s
respirations.
B.) Increase the set rate of respirations of the ventilator.
C.) Obtain arterial blood gases (ABGs) in one hour to evaluate the client’s status.
D.) Administer a paralytic agent to allow full ventilator support.
A.) Give sedation to allow the ventilator to adequately assist the client’s
respirations.
Rationale :The client is experiencing respiratory distress from fighting the
ventilator. The nurse should administer a sedative to relax and calm the client,
allowing the ventilator to provide adequate respiratory support
The healthcare provider prescribed propofol IV and succinylcholine IV for a client
who is being prepared for intubation. Which action should the nurse implement to
assist the healthcare provider during administration of these two drugs?
A.) Prepare propofol for sedation before giving succinylcholine, a paralytic.
B.) Succinylcholine should be prepared for administration first.
C.) Mix both medications at the same time in the same syringe.
D.) Question the administration and refused to provide propofol.
A.) Prepare propofol for sedation before giving succinylcholine, a paralytic.
Rationale :Propofol, a sedative-hypnotic, is used to sedate a client during
induction of anesthesia, and succinylcholine is a paralytic drug used to prevent
laryngospasm during intubation and to prevent the client’s resistance to intubation.
The client should be sedated before being paralyzed, which can be very stressful to
the client who is not able to move, breathe, or talk. The nurse should prepare
propofol for the administration by the healthcare provider first, then
succinylcholine can be given by the healthcare provider.
A client in the intensive care unit begins to manifest seizure activity while the
unlicensed assistive personnel (UAP) is providing a bedbath. The UAP pulls the
emergency call bell and calls for help. Which action by the UAP should the nurse
correct?
A.) Restraining the client’s extremities.
B.) Loosening restrictive clothing.
C.) Padding the raised side rails.
D.) Placing the client in a lateral position
A.) Restraining the client’s extremities.
Rationale :A client should be protected as much as possible during seizure
activity. The nurse should direct the UAP to refrain from restricting the client’s
extremities with restraints, which can cause injury to the client and the person who
is holding or applying restraints on the client.
A client is admitted to the intensive care unit due to a sharp blow to the head after
a fall while ice skating. Which assessment finding should the nurse report to the
healthcare provider that is consistent with increased intracranial pressure?
A.) Papilledema.
B.) Lump at the site of injury.
C.) Unilateral ptosis.
D.) Onsert of a headache.
A.) Papilledema.
Rationale :Papilledema is observed via ophthalmoscopic view of swelling around
the optic disc, which results from increased intracranial pressure (ICP) in the
cerebral vault. The nurse should report signs of increased ICP to the healthcare
provider immediately.
A client arrives in the emergency department experiencing difficulty breathing.
Which finding requires further assessment?
A.) Use of accessory respiratory muscles.
B.) Auscultation of crackles in lower lobes.
C.) Flushed skin.
D.) Production of white sputum
A.) Use of accessory respiratory muscles.
Rationale :A client who is experiencing dyspnea and is using accessory
respiratory muscles with severe respiratory effort requires further assessment and
management.
The post anesthesia care unit (PACU) nurse transfers a client to the intensive care
unit (ICU) and reports that the client received morphine sulfate 4 mg IV for pain of
8 on a scale of 1 to 10. On assessment in the ICU, the nurse observes that the client
is somnolent, difficult to arouse, and has a respiratory rate is 6 breaths/minute.
Which prescription should the nurse implement?
A.) Naloxone.
B.) Morphine sulfate.
C.) Albuterol.
D.) Fentanyl.
A.) Naloxone.
Rationale :The client is experiencing respiratory depression from the morphine.
The nurse should administer naloxone, the antidote for narcotic overdose.
A client arrives in the emergency department with a gunshot wound to the chest.
The client is short of breath, has tracheal deviation to the unaffected side of the
chest, and an O2 saturation of 84%. Which pathophysiologic process is
precipitating the client’s findings?
A.) Tension pneumothorax.
B.) Flail chest.
C.) Pulmonary contusion.
D.) Acute respiratory distress syndrome
A.) Tension pneumothorax
Rationale :A gunshot wound that penetrates the chest wall allows air to enter the
pleural space causing respiratory distress due to a tension pneumothorax that shifts
the trachea from midline and to the unaffected side of the chest.
A client is admitted to the emergency department with a flail chest after hitting the
steering wheel during a motor vehicle collision. Which pathophysiological
mechanism is associated with the client’s condition?
A.) Thoracic cage instability due to free-floating ribs and chest wall movement
contrary to normal respirations.
B.) Bronchial spasms that cause wheezing that is louder on exhalation than
inhalation.
C.) Increased pulmonary pressure causing coughing with large amounts of frothy
sputum.
D.) Chest constriction that causes severe shortness of breath that limits the ability
to say more than a few words.
A.) Thoracic cage instability due to free-floating ribs and chest wall movement
contrary to normal respirations.
Rationale :Trauma that disrupts the costal cartilage attachment of the ribs causing
a flail chest which is manifested by free-floating ribs moving the chest wall inward
with inhalation and outward with exhalation.
The nurse is providing care for a client who is comatose following a cardiac arrest
24-hours ago. Which physical assessment finding should the nurse determine to be
a predictor of a poor outcome?
A.) Lack of response to a sternal rub.
B.) Lack of corneal or papillary response.
C.) Lack of purposeful motor movement.
D.) Lack of response to verbal stimulation.
B.) Lack of corneal or papillary response.
Rationale :The two best predictors of poor outcomes for a comatose client who
has experienced a cardiac arrest are lack of corneal or papillary response at 24-
hours and lack of motor movement at 72-hours.
The nurse is assisting the healthcare provider with the insertion of a pulmonary
artery catheter for a client. The nurse should place the client in which position for
this procedure?
A.) Right lateral.
B.) Semi-Fowler.
C.) Trendelenberg.
D.) Dorsal recumbent.
C.) Trendelenberg
Rationale :Placing the client in the Trendelenburg position promotes easier venous
filling in the upper body to facilitate insertion of the catheter into the jugular vein
and minimizes the occurrence of an air embolism during the procedure.