Critical Care HESI
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1 . What assessment findings should he
nurse document in the electronic med-
Ans:
ical record for a client who is experienc-
Severe hypertension, diaphroresis, and
ing
flushing above the lesion
autonomic dysreflexia after a T-4 spinal
cord injury?
2 As the nurse is turning a client with
Ans:
a chest tube, the chest tube becomes
Have the client exhale forcefully and tape
dislodged from the pleural space. What
3 sides of a sterile gauze over the inser-
action
tion site
should the nurse take first?
3 . The nurse plans to administer a low
dose prescription for dopamine (Intropin)
to a client who is in septic shock. Which Ans:
physiological parameter should the Urinary Output
nurse use to evaluate a therapeutic re-
sponse to dopamine?
4 . The nurse assesses a male client
postoperatively who has an arterial line
in the radial artery. Assessment findings Ans:
include pallor, parastesia, and slow capil- Notify the HCP
lary refill in the client's right hand fingers.
What action should the nurse plan?
5 . A male client is admitted to the cardiac
intensive unit with chest pain that began
twelve hours ago. The nurse recognizes Ans:
increased ventricular ectopy? Based on Initiate the unit's antiarrhythmic protocol
this assessment finding, what actions is if symptomatic.
most important for the nurse to
implement?
6 . The nurse is assessing a client who
was admitted 24 hours ago to the critical
care unit following a motorcycle collision. Ans:
Which client finding requires intervention Change of PaCo2 to 55 mm Hg following
by the nurse to reduce the risk for com- ventilator setting adjustments
plication related to increased
intracranial pressure?
, Critical Care HESI
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7 . A client is receiving cardiopulmonary
resuscitation. After asystole is confirmed
in two leads and sending for the Ans:
transcutaneous pacemaker, which intra- Epinephrine
venous medication should be adminis-
tered?
8 . The nurse performs a prescribed neu-
rological check at the beginning of the
shift on a client who was admitted to the
Ans:
hospital with a subarachnoid brain at-
The client's previous GCS score
tack (stroke). The client's Glasgow coma
scale is 9. What information is most
important for the nurse to determine?
9 . The healthcare provider prescribes a
STAT computerized tomography without
contrast for a client who is exhibiting
signs of an acute change in the level of
Ans:
consciousness. The nurse is caring for
Administered the schedule medications
two additional intensive care clients and
prior to transporting the client to CT scan.
has
an unlicensed assistive personnel as-
signed to assist with the delivery of care.
What action should the nurse take?
10 . The healthcare provider prescribes
and IV fluid bolus for a client who was ad-
mitted two hours ago to the ICU because
of adrenal crisis. The client is confused Ans:
and uncooperative. The nurse has at- Ask another nurse to attempt insertion of
tempted two times to obtain IV access IV
without
success. Which intervention should the
nurse implement first?
11 . Arterial blood gas results indicate
that a client with respiratory failure who
is being mechanically ventilated has
respiratory acidosis. The ventilator rate
is set at 6 breaths/minute, pressure sup-
port at 10 cm H2O and oxygen
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