CRITICAL CARE HESI EXIT EXAM 2023-2024 ACTUAL
EXAM ALL 140 QUESTIONS AND CORRECT
ANSWERS|ALREADY GRADED A+
The nurse manager is assisting a nurse with improving organizational skills and time
management. Which nursing activity is the priority in pre-planning a schedule for selected
nursing activities in the daily assignment?
A. Tracheostomy tube suctioning.
B. Medication administration.
C. Colostomy care instruction.
D. Client personal hygiene. - ANSWER-B. Medication administration.
RATIONALE:
In developing organizational skills, medication administration is based on a prescribed schedule
that is time-sensitive in the delivery of nursing care and should be the priority in scheduling
nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes
precedence in providing care, the client's PRN need is less amenable to a preselected schedule.
(B and C) can be scheduled around time-sensitive delivery of care
What nursing delivery of care provides the nurse to plan and direct care of a group of clients
over a 24-hour period?
A. Case management.
B. Team nursing.
C. Primary nursing.
D. Functional nursing. - ANSWER-C. Primary nursing.
RATIONALE:
Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care
for clients around the clock. Functional nursing (D) is a care delivery model that provides client
care by assignment of functions or tasks. Team nursing (A) is a care delivery model where
assignments to a group of clients are provided by a mixed-staff team. Case management (C) is
,the delivery of care that uses a collaborative process of assessment, planning, facilitation, and
advocacy for options and services to meet an individual's health needs and promote quality
costeffective outcomes.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take
a break first. What is the most important basic guideline that the nurse should follow in resolving
the conflict?
A. Require the UAPs to reach a compromise.
B. Weigh the consequences of each possible solution.
C. Encourage the two to view the humor of the conflict.
D. Deal with issues and not personalities - ANSWER-D. Deal with issues and not personalities.
RATIONALE:
Dealing with the issues which are concrete, not personalities (A) which include emotional
reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not
resolve the conflict when diverse opinions are expressed emotionally.
The nurse is caring for a client who is unable to void. The plan of care establishes an
objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which
client response should the nurse document that indicates a successful outcome?
A. Demonstrates adequate fluid intake and output.
B. Verbalizes abdominal comfort without pressure.
C. Drinks 240 mL of fluid five times during the shift.
D. Voids at least 1000 mL between 7 am and 3 pm - ANSWER-C. Drinks 240 mL of fluid five times during
the shift
RATIONALE:
The nurse should evaluate the client's outcome by observing the client's performance of each
expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a
fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the
designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective,
,which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid
intake.
The nurse plans a teaching session with a client but postpones the planned session based on
which nursing problem?
A. Knowledge deficit regarding impending surgery.
B. Ineffective management of treatment regimen.
C. Activity intolerance related to postoperative pain.
D. Noncompliance with prescribed exercise plan. - ANSWER-C. Activity intolerance related to
postoperative pain
RATIONALE:
Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate in learning,
so the nursing diagnosis in (A) indicates a need to postpone teaching. (B, C, and D) indicate a
need for instruction.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks
the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should
the nurse respond?
A. "To protect you because you can get an infection very easily."
B. "Your condition could be spread to staff and other clients in the hospital."
C. "There are many forms of bacteria and germs in the hospital."
D. "After taking medication for 24 hours a gown and mask won't be needed." - ANSWER-A. "To protect
you because you can get an infection very easily."
RATIONALE:
Reverse isolation precaution implement measures to protect the client from exposure to
microorganisms from others (B). Although microbes are prevalent in all environments, (A) does
not adequately answer the child's question. Reverse isolation should be implemented until the
client's white blood cell increases (C). Neutropenia in this child does not place others (D) at risk
for infection.
, The nurse is giving discharge instructions to the parents of a newborn with a prescription for
home phototherapy. Which statement by a parent indicates understanding of the phototherapy?
A. "I should leave the baby under the light all of the time."
B. "I should dress the baby in light clothing when the baby is under the light."
C. "I need to change the baby's position every four hours."
D. "I will keep the baby's eyes covered when the baby is under the light." - ANSWER-D. "I will keep the
baby's eyes covered when the baby is under the light."
RATIONALE:
Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which
is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the
infant's eyes should be protected (C) by closing the eyes and placing patches over them before
placing the baby under the phototherapy light source. The baby's position should be changed
about every two hours, not (A), so that the light reaches all areas of the body to promote
conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be
removed from the light for feedings and diaper changes, but should receive phototherapy
exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose
as much skin as possible to the light (D).
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal
cannula, and complains of dry mouth. Which action should the nurse implement?
A. Apply a water soluble lubricant to the lips, oral mucosa and nares.
B. Put petroleum jelly on the lips and around the nasogastric tube.
C. Offer the client ice chips and instruct client to spit out the water.
D. Allow the client to drink water and record on the I and O record. - ANSWER-A. Apply a water soluble
lubricant to the lips, oral mucosa and nares.
RATIONALE:
To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the
mucous membranes moist (D). (A) is a petroleum-based product and should not be used because
EXAM ALL 140 QUESTIONS AND CORRECT
ANSWERS|ALREADY GRADED A+
The nurse manager is assisting a nurse with improving organizational skills and time
management. Which nursing activity is the priority in pre-planning a schedule for selected
nursing activities in the daily assignment?
A. Tracheostomy tube suctioning.
B. Medication administration.
C. Colostomy care instruction.
D. Client personal hygiene. - ANSWER-B. Medication administration.
RATIONALE:
In developing organizational skills, medication administration is based on a prescribed schedule
that is time-sensitive in the delivery of nursing care and should be the priority in scheduling
nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes
precedence in providing care, the client's PRN need is less amenable to a preselected schedule.
(B and C) can be scheduled around time-sensitive delivery of care
What nursing delivery of care provides the nurse to plan and direct care of a group of clients
over a 24-hour period?
A. Case management.
B. Team nursing.
C. Primary nursing.
D. Functional nursing. - ANSWER-C. Primary nursing.
RATIONALE:
Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care
for clients around the clock. Functional nursing (D) is a care delivery model that provides client
care by assignment of functions or tasks. Team nursing (A) is a care delivery model where
assignments to a group of clients are provided by a mixed-staff team. Case management (C) is
,the delivery of care that uses a collaborative process of assessment, planning, facilitation, and
advocacy for options and services to meet an individual's health needs and promote quality
costeffective outcomes.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take
a break first. What is the most important basic guideline that the nurse should follow in resolving
the conflict?
A. Require the UAPs to reach a compromise.
B. Weigh the consequences of each possible solution.
C. Encourage the two to view the humor of the conflict.
D. Deal with issues and not personalities - ANSWER-D. Deal with issues and not personalities.
RATIONALE:
Dealing with the issues which are concrete, not personalities (A) which include emotional
reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not
resolve the conflict when diverse opinions are expressed emotionally.
The nurse is caring for a client who is unable to void. The plan of care establishes an
objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which
client response should the nurse document that indicates a successful outcome?
A. Demonstrates adequate fluid intake and output.
B. Verbalizes abdominal comfort without pressure.
C. Drinks 240 mL of fluid five times during the shift.
D. Voids at least 1000 mL between 7 am and 3 pm - ANSWER-C. Drinks 240 mL of fluid five times during
the shift
RATIONALE:
The nurse should evaluate the client's outcome by observing the client's performance of each
expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a
fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the
designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective,
,which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid
intake.
The nurse plans a teaching session with a client but postpones the planned session based on
which nursing problem?
A. Knowledge deficit regarding impending surgery.
B. Ineffective management of treatment regimen.
C. Activity intolerance related to postoperative pain.
D. Noncompliance with prescribed exercise plan. - ANSWER-C. Activity intolerance related to
postoperative pain
RATIONALE:
Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate in learning,
so the nursing diagnosis in (A) indicates a need to postpone teaching. (B, C, and D) indicate a
need for instruction.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks
the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should
the nurse respond?
A. "To protect you because you can get an infection very easily."
B. "Your condition could be spread to staff and other clients in the hospital."
C. "There are many forms of bacteria and germs in the hospital."
D. "After taking medication for 24 hours a gown and mask won't be needed." - ANSWER-A. "To protect
you because you can get an infection very easily."
RATIONALE:
Reverse isolation precaution implement measures to protect the client from exposure to
microorganisms from others (B). Although microbes are prevalent in all environments, (A) does
not adequately answer the child's question. Reverse isolation should be implemented until the
client's white blood cell increases (C). Neutropenia in this child does not place others (D) at risk
for infection.
, The nurse is giving discharge instructions to the parents of a newborn with a prescription for
home phototherapy. Which statement by a parent indicates understanding of the phototherapy?
A. "I should leave the baby under the light all of the time."
B. "I should dress the baby in light clothing when the baby is under the light."
C. "I need to change the baby's position every four hours."
D. "I will keep the baby's eyes covered when the baby is under the light." - ANSWER-D. "I will keep the
baby's eyes covered when the baby is under the light."
RATIONALE:
Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which
is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the
infant's eyes should be protected (C) by closing the eyes and placing patches over them before
placing the baby under the phototherapy light source. The baby's position should be changed
about every two hours, not (A), so that the light reaches all areas of the body to promote
conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be
removed from the light for feedings and diaper changes, but should receive phototherapy
exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose
as much skin as possible to the light (D).
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal
cannula, and complains of dry mouth. Which action should the nurse implement?
A. Apply a water soluble lubricant to the lips, oral mucosa and nares.
B. Put petroleum jelly on the lips and around the nasogastric tube.
C. Offer the client ice chips and instruct client to spit out the water.
D. Allow the client to drink water and record on the I and O record. - ANSWER-A. Apply a water soluble
lubricant to the lips, oral mucosa and nares.
RATIONALE:
To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the
mucous membranes moist (D). (A) is a petroleum-based product and should not be used because
