HESI RN CRITICAL CARE
The nurse is responsible for triage of injured residents of an apartment
building that collapsed during a tornado. Which client should the
emergency personnel see FIRST?
1. A 38-year-old client with potential fracture left femur. Blood pressure
110/78, pulse 92/minute, shallow respirations at 16/minute.
2. A 42-year-old client with ecchymotic areas on the left anterior and
posterior chest. Blood pressure 142/90, pulse 88/minute, shallow
respirations at 20/minute.
3. A 48-year-old client with severe head trauma. Blood pressure 168/52,
pulse 58 per minute, irregular respirations at 12/minute.
4. A 64-year-old client complaining of left hand and wrist pain asking,
“Where am I?” Blood pressure 128/72, pulse 88/minute, respirations
unlabored at 16/minute – ANSWER- 3
The nurse cares for a client diagnosed with Crohn’s disease. The nurse
instructs the client about diet. Which menu selection indicates to the
nurse that teaching is effective?
1. Cheeseburger on a whole-wheat bun, french fries, and an apple.
2. Tomato soup, saltines, and a slice of unfrosted angel food cake.
3. Baked cod, biscuit without butter, fruit roll-up.
- Macaroni and cheese, coleslaw, 2 macaroon cookies – ANSWER- 3
The nursing team consists of one RN, one LPN/LVN and two nursing
assistive personnel (NAPs). Which assignment is MOST appropriate for
the LPN/LVN? - A 38-year-old client diagnosed with Guillain-Barré syndrome
receiving plasmapheresis therapy. - A 72-year-old client admitted yesterday with a 10-day history of oral
antibiotic therapy and a 24-hour history of watery diarrhea. - A 78-year-old client diagnosed with a thrombotic cerebrovascular
accident 5 days ago. - A 86-year-old client just admitted with malaise, a productive cough,
and WBC 17,000 mm3. – ANSWER- 3
The nurse cares for a client during a 24-hour urine specimen collection.
Several hours later, the client tells the nurse that she has started to
menstruate. Which action by the nurse is MOST appropriate? - Inform the health care provider that the client is menstruating.
- Send the urine collected prior to the onset of the client’s menstruation
to the lab. - Insert an indwelling bladder catheter during the remainder of the
collection period. - Request a separate urine collection container from the laboratory to be
used during the remainder of the urine collection period. – ANSWER- 1
The nurse cares for the client in the recovery room after a knee surgery
procedure. The client has an oral airway in place. Which is the BEST
indicator that the oral airway can be removed?
- The client has a forceful cough during repositioning
.2. The client tries to chew on the oral airway.. - The client tries to push the airway out with his tongue.
- The client is able to swallow. – ANSWER- 2
The nurse cares for clients in the antepartum clinic. Which client should
the nurse see FIRST? - An 18-year-old multigravida client at 28 weeks gestation with a
positive indirect Coombs’ test. - A 24-year-old multigravida client at 32 weeks gestation with
moderate facial edema. - A 30-year-old client at 26 weeks gestation with bilateral yellow breast
exudate. - A 43-year-old primigravida client at 18 weeks of gestation reporting
an absence of fetal movement. – ANSWER- 2
The nurse instructs a client about include digoxin (Lanoxin), furosemide
(Lasix), spironolactone (Aldactone), and a low-sodium diet. Which
statement by the client indicates the need for further instruction? - “I should weigh myself every morning and call the health care
provider if I gain more than a couple of pounds in a few days.” - “I should call the health care provider immediately if I start to feel
nauseated or have difficulty breathing with normal activities.”
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