Critical Care HESI Remediation
A client comes to the emergency department with severe and gnawing epigastric pain. The client reports accidently doubling the warfarin sodium dose for the last three days. What should the nurse expect to find upon assessment? a. Melena. b. Ascites. c. Jaundice. d. Vascular spiders.
a
A client's admitted to the intensive care unit diagnosed with stage 5 chronic kidney disease assessment includes crackles in the lungs, periorbital edema, anuric, muscle cramps and paresthesia. The nurse should anticipate the health care provider to prescribe which treatment? a. Renal dialysis. b. Nitroglycerin. c. Albuterol inhalation. d. Furosemide intravenously.
a
The nurse is assessing a client who is 12 hours post spinal cord injury at C-6. The client is flushed in appearance with hot and dry skin. The client's heart rate has dropped to 58 beats per minute and blood pressure dropped to 86/52 mmHg. The client's signs and symptoms are indicative of which complication? a. Spinal shock. b. Neurogenic shock. c. Cardiogenic shock. d. Hemorrhagic shock.
b
What should a nurse ensure is done for a client who is placed in a hip spica cast to prevent abdominal distention, epigastric pain, nausea and vomiting caused by a partial or complete intestinal obstruction? a. Obtaining a prescription for a stool softener. b. A square hole in the stomach area of the cast is cut out. c. Encouraging the client to drink 1.5-2 liters of fluid/day. d. Providing a diet with whole grains, raw fruit and vegetables.
b
Which action should the nurse take to reduce the risk of infection in a client with an enterocutaneous fistula? a. Stop enteral feedings. b. Optimize gravity drainage of fistula. c. Check temperature orally every 2 hours. d. Administer antibiotics as needed.
b
The critical care nurse is completing a physical assessment on a client admitted with diabetic ketoacidosis. Which assessment finding should the nurse anticipate? a. Cool, clammy skin. b. Hypertension. c. Kussmaul respirations. d. No change in LOC.
c
The nurse is performing an abdominal assessment on a client with suspected acute gastrointestinal bleeding. Which finding should the nurse anticipate? a. Hot extremities. b. Pain that radiates to the left leg. c. Rigid abdomen. d. Hypoactive bowel sounds.
c
A client has just been diagnosed with nephrogenic diabetes insipidus. Which assessment finding should the nurse interpret as a sign of electrolyte imbalance? a. Nocturia. b. Poor skin turgor. c. Increased thirst. d. Leg cramps.
d
The nurse is caring for a client who is showing signs of a tension pneumothorax. Which intervention should the nurse be prepared to implement? a. Application of occlusive dressing. b. Emergency thoracotomy. c. Insertion of chest tube. d. Needle thoracostomy.
d
Which sign should alert the nurse of a possible pneumothorax in a client with an acute asthma exacerbation? a. Hyperresonance found on percussion. b. Decreased tactile fremitus. c. Wheezing heard on auscultation. d. Hyperinflated chest.
a
Which symptom should the nurse expect in a client with uremia? a. Metallic taste. b. Increased appetite. c. Excessive sleepiness. d. Clammy skin.
a
The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). What expected patient outcome should the nurse include in the plan of care? a. The client will remain free of infection. b. The client will maintain cool, dry skin. c. The client will remain hypotensive. d. The client will return to baseline activity level by day 3.
a
The nurse is preparing discharge instructions for a client diagnosed with acute coronary syndrome. Which is an expected outcome when effective client education is provided? a. The client will verbalize lifestyle changes that are needed. b. The client will require additional teaching. c. The client will question the need to take hypertensive medications. d. The client will refuse to adhere to a cardiac diet.
a
A mass casualty has been called at a level-one trauma center involving a motor vehicle collision. The triage nurse uses the color coding system to categorize the clients. Which color should the nurse assign a client who is bleeding profusely from the neck? a. Red. b. Yellow. c. Green. d. Black.
a
A middle-aged client who was admitted for a multi-traumatic accident is suspected of developing "Systemic Inflammatory Response" (SIRS). Which set of vital signs would the nurse anticipate the client to display? a. RR- 24 breaths/min; HR- 120 beats/minute; and temperature of 100.8??? F (38.2??? C). b. RR- 18 breaths/min; HR- 90 beats/minute; and temperature of 100??? F (37.2??? C). c. RR- 12 breaths/min; HR- 60 beats/minute; and temperature of 96.8??? F (3???6 C). d. RR- 36 breaths/min; HR- 86 beats/minute; and temperature of 97.4??? F (36.3??? C).
a
The nurse is assessing a client who is experiencing shortness of breath, intercostal retractions, nasal flaring, inspiratory and expiratory wheezing, who has not not shown any respiratory improvement after two administrations of albuterol nebulizer treatments. Which is a common trigger for acute asthma exacerbation? a. Ingested allergen. b. Exposure to warm air. c. Hypocapnia. d. Inactivity.
a
The nurse is assessing a young adult client who reports joint discomfort and pain. Upon inspection the nurse notes the client has very long hands and feet, and a very tall, thin build. On physical assessment, the nurse identifies a mitral valve murmur and scoliosis. Which condition is consistent with the nurse's assessment? a. Marfan syndrome. b. Cushing's syndrome. c. Fibromyalgia syndrome. d. Polymyalgia rheumatic syndrome.
a
The nurse is caring for a client who recently had a myocardial infarction. Which is the first action the nurse should take when a client begins exhibiting signs of cardiogenic shock? a. Prepare to administer ionotropic agents. b. Encourage the client to breath slowly. c. Place the client in prone position. d. Give the client aspirin.
a
The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). What expected patient outcome should the nurse include in the plan of care? a The client will remain free of infection. b. The client will maintain cool, dry skin. c. The client will remain hypotensive. d. The client will return to baseline activity level by day 3.
a
The nurse is preparing discharge instructions for a client diagnosed with acute coronary syndrome. Which is an expected outcome when effective client education is provided? a. The client will verbalize lifestyle changes that are needed. b. The client will require additional teaching. c. The client will question the need to take hypertensive medications. d. qThe client will refuse to adhere to a cardiac diet.
a
The nurse is preparing to assess a client in renal failure. Which question should the nurse ask in order to gain an adequate understanding of the client's health history? a. "Do you often wake up at night to go the bathroom?" b. "How much sleep do you get each day?" c. "How often do you exercise?" d. "Do you follow a low-fat diet?"
a
The nurse is preparing to take a client off of a ventilator. Which type of therapy should the nurse be prepared to administer to keep the client comfortable? a. Morphine sulfate. b. Tylenol PO. c. Increased intravenous fluids. d. Hydralazine.
a
The nurse is providing care to a client with adrenal insufficiency. Which action should the nurse be prepared to take? a. Replace cortisol. b. Manage hypertension. c. Encourage the client to take in oral fluids. d. Diurese the client.
a
The nurse is providing discharge instructions to a client in renal failure. Which recommendation should the nurse offer when educating the client? a. Keep skin moisturized. b. Avoid phosphate binders. c. Follow a high-protein diet regimen. d. Consume high-potassium foods.
a
The nurse is providing education to a client and family on hospice. Which information should the nurse provide about hospice care? a. "Hospice views dying as a natural process." b. "Hospice assists the family in finding a cure." c. "Pain medications are not given in hospice." d. "Hospice follows a naturopathic model of healing."
a
The nurse is providing end-of-life care for a client. What should the nurse view as the desired outcome of care? a. Relieve suffering. b. Prevent skin breakdown. c. Increase client mobility. d. Facilitate healing through rest.
a
The nurse is providing end-of-life care for a client. Which sign indicates that the client is suffering? a. Nasal flaring. b. Yawning. c. Warm, dry skin. d. Eupnea.
a
The nurse is providing fluid resuscitation to a client with acute pancreatitis. Which action should the nurse include in the plan of care for this client? a. Evaluate character of all fluids lost. b. Administer isotonic IV fluids. c. Weigh the client every other day. d. Maintain a small bore IV.
a
The nurse is reviewing the history of a client who presents with upper abdominal pain. Which entry in the client's history may cause the nurse to suspect acute pancreatitis? a. Excessive alcohol consumption. b. Lethargy. c. Constipation. d. Kidney stones.
a
The nurse is working with the medical team to stabilize a client who is in shock. The nurse knows the physician will likely order a fluid challenge. Which action should the nurse take first? a. Establish two IV catheters. b. Begin warming IV fluids. c. Encourage the client to take fluids in orally. d. Obtain orthostatic blood pressures.
a
The nurse performs a 12-lead electrocardiogram (ECG) on a client who is in the first hour of care after a myocardial infarction (MI). The client's T-waves appear tall and peaked. How should the nurse interpret this finding? a. This is a normal finding in the first hour after an MI. b. This is a warning sign for an impending massive heart attack. c. This as abnormal because T-waves are typically inverted during an acute MI. d. This tracing should be compared with a previous 12-lead ECG prior to interpretation.
a
What should the nurse identify as the primary goal when planning end-of-life nursing care? a. Make the client as comfortable as possible. b. Allow the client's family to reconnect with relatives. c. Surround the client with family and friends. d. Help make the client's family feel supported.
a
When caring for a client with acute coronary syndrome, which action should the nurse take to reduce the risk of further injury? a. Be prepared to begin antithrombin therapy. b. Begin discharge education on diet. c. Increase the client's physical activity. d. Stop intravenous fluids.
a
Which action is the priority when caring for a client with diabetic ketoacidosis? a. Initiate an intravenous insulin infusion. b. Maintain blood glucose levels at 200 mg/dl or lower. c. Administer oral hypoglycemic medications. d. Manage potassium imbalance.
a
Which action should the nurse perform to support the client and family during the dying process? a. Assure the family that the client will not die alone. b. Avoid checking on the patient too often. c. Adjust medications to keep the client more alert. d. Allow only immediate family to visit.
a
Which action should the nurse take to help the family understand a client's end-of-life care and progress? a. Provide updates about the client's condition. b. Leave the family alone to grieve. c. Restrict visiting hours for the client's privacy. d. Avoid discussions related to the client's death.
a
Which action should the nurse take when providing end-of-life care to a client and family? a. Ask the family if they would like to have a pastor or priest see the client. b. Check on the client every 4 hours to ensure the family's privacy. c. Request that the family step out of the room when providing care to the client. d. Withdraw pain medication to allow the client to be more alert.
a
Which assessment finding indicates a client is progressing into stage II of shock? a. "Bowel sounds are diminished." b. "Skin is hot and flushed." c. "Slow, labored breathing begins." d. "Heart rate decreases."
a
Which implementation should the nurse perform for a client with myasthenia gravis? a. Provide pulmonary toilet every two hours when the client is awake. b. Provide the client with extra snacks throughout the day. c. Allow the client time to leave the floor with family. d. Monitor pulse oximetry every 8 hours.
a
Which medication is contraindicated for a client with renal failure? a. Ibuprofen. b. Coumadin. c. Lasix. d. Lipitor.
a
While monitoring a client with adrenal insufficiency, the nurse notices that the client's vital signs are beginning to deteriorate. Which action should the nurse take? a. Call the physician. b. Complete a full physicial assessment. c. Encourage the client to ambulate. d. Decrease the rate of intravenous fluids.
a
client is admitted to the coronary intensive care unit with a diagnosed acute heart failure (HF) and myocardial infarction (MI). Which medication would the nurse anticipate the healthcare provider to prescribed to the client to decrease the preload and afterload, slow down their respirations, and reduce their anxiety and pain due to the MI? a. Enalapril (Vasotec). b. Morphine sulfate (Contin, MSIR). c. Hydrochlorothiazide (HCTZ, Urozide). d. Diazepam (Valium, Diastat, Diazemuls).
b
A client is admitted to the coronary intensive care unit with a diagnosed acute heart failure (HF) and myocardial infarction (MI). Which medication would the nurse anticipate the healthcare provider to prescribed to the client to decrease the preload and afterload, slow down their respirations, and reduce their anxiety and pain due to the MI? a. Enalapril (Vasotec). b. Morphine sulfate (Contin, MSIR). c. Hydrochlorothiazide (HCTZ, Urozide). d. Diazepam (Valium, Diastat, Diazemuls).
b
A client with pneumonia is brought to the emergency department with a history of not taking their medication for hypothyroidism and is suspected to have myxedema coma. Which expected outcome should the nurse expect to find during assessment? a. Diarrhea. b. Poor memory. c. Heat intolerance. d. Manic behavior.
b
An arterial blood gas (ABG) analysis is drawn for a client. The results show pH of 7.30; PaCO2 of 68 mm Hg and an HCO3 of 24 mEq/L. What should the nurse interpret this blood gas as? a. Compensated metabolic alkalosis. b. Uncompensated respiratory acidosis. c. Compensated metabolic acidosis. d. Uncompensated respiratory alkalosis.
b
The nurse assesses a client with suspected acute pericarditis. Which assessment finding is most consistent with this condition? a. Slow deep breathing. b. Stabbing chest pain. c. Bradycardia. d. Pain relieved by supine position.
b
The nurse is assisting in setting up hospice care in the client's home. Which action should the nurse take to ensure a smooth transfer? a. Allow the family to arrange the transfer. b. Keep the client and family informed throughout the transfer process. c. Encourage the client to decide when the transfer should take place. d. Ask the physician to manage the transfer.
b
The nurse is caring for a client with chronic hepatic failure who has developed refractory ascites who has not responded to traditional diuretics. Which action should the nurse take to manage the accumulation of ascites? a. Limit sodium intake to 2,000 mg per day. b. Administer mannitol. c. Prepare the client for a peritoneovenous shunt. d. Limit fluid intake to 500 ml per day.
b
The nurse is planning care for a client who was just diagnosed with acute pericarditis. Which screening test should the nurse educate the client about? a. Creatinine clearance. b. 12-lead electrocardiogram. c. Dobutamine stress test. d. Blood transfusion.
b
The nurse is preparing a client for discharge after a percutaneous coronary intervention. Which statement by the client indicates that teaching has been effective? a. "I no longer need medications now that I am all cleaned out." b. "I should report fainting to my cardiologist." c. "I'll follow up with my cardiologist if needed." d. "I should begin exercising once I return home."
b
What action should the nurse take to reduce the risk of infection for a client with acute pancreatitis? a. Administer prophylactic antibiotics. b. Monitor WBC count. c. Obtain blood cultures when the client is afebrile. d. Check body temperature every 8 hours.
b
Which assessment should the nurse perform on a client with suspected renal failure? a. Diet log. b. Orthostatic blood pressure. c. List of supplements. d. Surgical history.
b
Which finding should the nurse expect when assessing a client with acute kidney failure? a. Increased appetite. b. Peripheral edema. c. Hyperactivity. d. Cool, clammy skin.
b
Which medication should the nurse anticipate the healthcare provider to prescribe for a client who has just undergone a coronary artery stent placement? a. Losartan. b. Warfarin. c. Atropine. d. Verapamil.
b
Which statement by the nurse is important in determining the plan of care for a victim of a stab wound. a. "Stab victims should be placed in supine position." b. "Length of the impaling object is an important consideration." c. "Stab wounds are considered high-velocity injuries." d. "Stab victims should be given blood products immediately".
b
A client with hydrocephalus has been admitted to the critical care unit. Which assessment finding should the nurse report to the physician? a. Oxygen level of 95%. b. Temperature of 98.9. c. Pulse of 42. d. Blood pressure of 126/82.
c
A nurse who is caring for a client diagnosed with Graves disease suspects the client has progressed in to a thyrotoxicosis crisis. Which assessment finding would support this suspicion? a. Bradycardia. b. Hypertension. c. Profuse sweating. d. Hypothermia.
c
An unstable client with hyperglycemic hyperosmolar syndrome (HHS) has been assigned to the nurse. Which action should the nurse take initially? a. Insert a urinary catheter. b. Prepare to administer isotonic IV fluids. c. Evaluate the client's airway. d. Place two large bore IVs.
c
During the physical assessment, which finding should the nurse interpret as a possible indication of meningitis? a. Left flank pain. b. Lethargy. c. Stiff neck sign. d. Hyperglycemia.
c
The nurse is caring for a client who is at risk for developing pneumonia. Which action should the nurse take to decrease the risk of infection? a. Encourage the client to stay in bed and rest. b. Maintain an option suction system when suctioning the client. c. Teach the client how to cough and deep breathe. d. Implement protective isolation precautions.
c
The nurse is caring for a client who just been brought into the emergency department after a myocardial infarction. Which action is the priority for this client? a. Administer pain medications. b. Begin educating the client about what to expect in the cath lab. c. Administer 2-4L oxygen by nasal cannula. d. Obtain an electrocardiogram.
c
The nurse is preparing to assess a client with acute adrenal insufficiency. Which findings should the nurse anticipate during the client's assessment? a. Increased appetite. b. Hypokalemia. c. Nausea and vomiting. d. Inability to fall asleep at night.
c
What nursing care plan goal should the nurse establish for a client with multiple organ dysfunction syndrome (MODS)? a. Improved mobility. b. Removal of all medications. c. Adequate tissue oxygenation. d. Increased oral food intake.
c
When caring for a client in renal failure, which symptoms should the nurse interpret as an indication of hyperkalemia during the oliguric phase? a. General fatigue and irritation. b. Increased appetite and restlessness. c. Muscle weakness and paresthesia. d. Confusion and itching.
c
When creating a care plan for a client with acute pancreatitis, which medication should the nurse include for pain relief? a. Morphine. b. Meperidine. c. Hydromorphone. d. Ibuprofen.
c
Which action should the nurse take when caring for a client with a spinal injury who suddenly begins showing signs of autonomic dysreflexia? a. Turn the client every 4-6 hours. b. Monitor blood pressure every 2-3 hours. c. Elevate the head of the bed. d. Encourage the client to ambulate.
c
Which goal should the nurse include in the care plan for a client with myasthenia gravis within the first 24 hours of treatment? a. PaO2 equal to 70. b. PaCO2 equal to 60. c. O2 saturation greater than 95%. d. RR of 22 breaths/min.
c
Which statement is true about the development of the complication of primary spontaneous pneumothorax? a. "It generally occurs during pregnancy." b. "It is a life-threatening condition." c. "It occurs more often in men who smoke." d. "It occurs during exercise."
c
A 28-year-old client is exhibiting signs and symptoms of confusion, severe muscle weakness, tachycardia and hypotension and episodic of vomiting and constipation. The client has asthma and has been prescribed prednisone (Rayos, Winpred) and albuterol inhaler for the past year. Their vital signs are T- 97.8° F (36.6° C); P- 90; B/P 86/48 with lab values of sodium 130mmol/L; potassium 5.9mmol/L and calcium 10.3mg/dL. Which condition is the client most likely experiencing? a. What have you eaten in the last 24 hours? b. How often do you have to use your albuterol inhaler? c. Are you currently taken any SSRI's or MAOIs medication? d. When was the last time you took the prednisone medication?
d
A client with increased intracranial pressure has not had a bowel movement in three days. Which should the nurse anticipate will be administered to the client? a. Vegetables. b. Milk of magnesia. c. Prune juice. d. Docusate sodium.
d
A family member is visiting a client in the critical care unit. During the visit, the client has a cardiac arrest. As resuscitation efforts begin, what action should the nurse take with the visitor? a. Contact the chaplain to take the family member to the chapel. b. Have another nurse escort the family member to the waiting room. c. Keep the family member updated, as they wait outside the room. d. Upon the family member's request, allow the person to remain in the room.
d
The nurse is caring for a client in acute respiratory failure. Which goal should the nurse include in the care plan? a. Respiratory rate will be 30 breaths/min within 24-48 hours after initiation of treatment. b. The client will be weaned from the ventilator within 24-48 hours after initiation of treatment. c. Blood pH will be between 7.50-7.60 within 2-4 hours after initiation of treatment. d. The client has a PaO2 greater than 80 mmHg within 2-4 hours of initiation of treatment.
d
The nurse is educating a student nurse about collaborative care methods used with clients with increased intracranial pressure (IICP). Which method is appropriate treatment for clients with IICP? a. "Anti-hypertensives are considered first line therapy in client's with ICP." b. "Intravenous calcium antagonists increase perfusion." c. "Glycerin has been clinically proven to increase ICP and should not be used." d. "Clients given mannitol should be monitored for electrolyte imbalances."
d
The nurse is preparing a client for an esophagogastroduodenoscopy (EGD) following an episode of acute gastrointestinal bleeding. The client asks why the EGD is being performed. Which reason should the nurse give? a. To rule out malignancy. b. To remove intestinal obstructions. c. To cauterize the site. d. To locate the source of bleeding.
d
The nurse is providing care for a client diagnosed with acute infective endocarditis. Which symptom should the nurse expect to find on assessment in the late infective stage? a. Bradycardia. b. Increased appetite. c. Extremity pain. d. Petechiae.
d
What is the highest priority of nursing care in ventilator management of clients with acute respiratory distress syndrome? a. "The highest priority is nutrition support." b. "The highest priority is repositioning the client every 2 hours." c. "The highest priority is to reduce anxiety." d. "The highest priority is to protect the functional lung."
d
Which action should the nurse recognize as the care priority for a client with acute renal failure? a. Introduce the client to a low sodium diet. b. Make sure the client is safe in the home. c. Prevent disorientation in the hospital. d. Identify the contributing causes of the initial injury.
d
Which assessment finding indicates that a client is in progressive (stage III) of shock? a. Eupnea. b. Active bowl sounds. c. Normal sinus rhythm. d. Cold, clammy skin.
d
Which assessment finding is the nurse likely to observe in a client receiving treatment for status epilepticus? a. Nocturia. b. Slip and fall when ambulating. c. Decreased appetite. d. Repetitive lip smacking.
d
Which assessment finding should the nurse anticipate in a client experiencing an acute asthma exacerbation? a. Decreased nasal secretions. b. Frequent productive cough. c. Answering questions in full sentences. d. Prolonged phase of forced expiration.
d
Which assessment finding should the nurse expect in a client with a subarachnoid hemorrhage (SAH) complicated by acute hydrocephalus? a. Incontinence at 10 days after initial hemorrhage. b. Gradual onset of confusion within 1-7 days of initial hemorrhage. c. Presence of sucking frontal lobe reflexes 5 days after initial hemorrhage. d. Sudden onset of coma within 24 hours of initial hemorrhage.
d