HESI CRITICAL CARE, CRITICAL CARE
NURSING EXAM, HESI TEST BANK, HESI
PRACTICE EXAM, ADVAN CED NURSING
QUESTIONS, VERIFIED HESI ANSWERS,
CRITICAL CARE TEST PREP
Question : A 56-year-old female client is receiving
intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?(a) The nurse who is caring for another client receiving intracavitary radiation.(b) A nurse with Marfan's syndrome who is postmenopausal.(c) A nurse with oncology experience who may be pregnant.(d) The nurse who is caring for another client who has Clostridium difficile.
CORRECT ANSWER: B. A nurse with Marfan's syndrome
who is postmenopausal.
RATIONALE:
A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source is in place.A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any one staff member's exposure to the calculated time span based on the half-life of
radium, such as the number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the immune response in the client who should not be exposed to the potential inadvertent transmission of an infectious organism (D).
Question : A client who has active tuberculosis (TB) is
admitted to the medical unit. What action is most important for the nurse to implement?(a) Fit the client with a respirator mask.(b) Assign the client to a negative air-flow room.(c) Don a clean gown for client care.(d) Place an isolation cart in the hallway
CORRECT ANSWER: Assign the client to a negative air-
flow room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment.
Question : A client is receiving atenolol (Tenormin) 25 mg
PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?(a) Measure the blood pressure.(b) Reassess the apical pulse.(c) Notify the healthcare provider.(d) Administer the medication.
CORRECT ANSWER: Administer the medication
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time.
Question : The nurse is assessing a client and identifies a
bruit over the thyroid. This finding is consistent with which interpretation?(a) Hypothyroidism.(b) Thyroid cyst.(c) Thyroid cancer.(d) Hyperthyroidism
CORRECT ANSWER: Hyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the
thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular
vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).
Question : A 6-year-old child is alert but quiet when brought
to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?(a) Hematemesis and abdominal distention.(b) Asymmetry of the face and eye movements.(c) Rhinorrhoea or otorrhoea with Halo sign.(d) Abnormal position and movement of the arm.
CORRECT ANSWER: Rhinorrhoea or otorrhoea with Halo
sign.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries.