HESI 4 Critical Care MCA 3 Practice Test

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• Which assessment finding alerts the nurse to increasing intracranial pressure?
• Which of the following conditions would receive a green tag according to the disaster triage system?
• During assessment of a client with a left pneumothorax, which finding is expected?
• Which color tag indicates a client who requires immediate treatment in disaster triage?
• If a patient with suspected pulmonary embolism has a negative D-dimer test, what does this suggest in a patient with low pretest probability?
• A patient with traumatic brain injury is scheduled for decompressive craniectomy. Which statement correctly describes this procedure?
• A recently extubated client in the PACU develops stridor and respiratory difficulty. Which action should the nurse implement first?
• If a patient shows a rhythm consistent with ventricular fibrillation, what should be the nurse's priority action?
• For a client on hospice undergoing palliative neck radiation, which assessment should be a priority?
• The nurse assists with insertion of a pulmonary artery catheter for a client in cardiogenic shock. Which action is most important to prevent life-threatening complications?
• A client who is 4 days postoperative after abdominal surgery reports sudden onset of dyspnea. Vital signs show heart rate 120 bpm and respiratory rate 35/min. Which diagnostic test should the nurse anticipate the healthcare provider prescribing?
• For surface rewarming, which temperature is used to heat intravenous fluids?
• What is the normal arterial pH range?
• During triage of a high-speed motor vehicle collision, what information is most important for the triage nurse to obtain from the paramedics?
• In hyperkalemia, which ECG finding is most characteristic?
• Hospital Incident Command System (HICS) is a component of which system that standardizes disaster operations?
• Prior to obtaining an arterial blood gas sample from a patient with hypoxia due to cardiomyopathy, which assessment should the nurse perform?
• In pulmonary edema caused by hypervolemia, which statement is most typical regarding blood pressure?
• What should be the first aid action taken for a brown recluse spider bite?
• An arterial blood gas from a mechanically ventilated client shows pH 7.37; PaCO2 30 mmHg; HCO3- 28 mEq/L. Which condition best explains these values?
• Two days after cardiac bypass, mediastinal chest tube to water seal; patient uses incentive spirometer hourly. Which assessment finding warrants nursing intervention?
• What does thallium scanning assess regarding the heart?
• The postanesthesia care unit nurse caring for a client who had a craniotomy for a meningioma would monitor for which specific clinical manifestation?
• According to the Emergency Preparedness and Response Plan, what is the function of the medical command physician?
• For a patient with hyperglycemic hyperosmolar syndrome (HHS) on an insulin drip, which action should the nurse perform during the infusion?
• Kehr's sign is most strongly associated with injury to which organ?
• A 3-second ECG tracing shows four normal QRS complexes and no signs of pathology. How would you interpret this tracing?
• A client at 36 weeks of gestation is admitted with signs of placental separation (abruptio placentae). Which immediate intervention is most appropriate?
• Which type of shock would be most likely in a client with a ruptured abdominal aortic aneurysm?
• What does calibrating the hemodynamic monitor by zeroing the transducer at the start of each shift accomplish?
• In disaster triage tagging, which color tag indicates the patient is dead or expected to die and not prioritized for immediate care?
• A client with diabetic ketoacidosis has rapid, deep, and labored breathing. What term should the nurse use to document the breathing pattern?
• A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. Which is the priority intervention?
• Which biological agent is treated with antitoxin?
• Which auscultation finding is commonly associated with COPD?
• Which statement about green-tagged patients is true?
• An older patient recovering from a bowel procedure uses a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide about the PCA use?
• A client has partial-thickness burns. Which statement is true about this type of burn?
• Which method is most readily available for communication with an intubated patient?
• Which condition is triaged as urgent among these client scenarios?
• Which area of assessment is included in the Glasgow Coma Scale?
• A patient with an autograft reports curling edges of the graft. Which action is most appropriate?
• Infective endocarditis can present with which cardiac finding associated with heart failure?
• A telemetry tracing shows a pacing spike with a delay before the QRS. What is the interpretation?
• A client with signs of sepsis presents with hypotension (BP 88/24), fever 101 F, tachycardia. Which intervention should the nurse implement first?
• Which pair of findings meets the diagnostic criteria for SIRS?
• Which emergency medical service agency offers first aid stations and special-need shelters during disasters?
• For surface rewarming, what is the maximum temperature to heat lavage fluids?
• Postoperative assessment after an aorta repair shows improved blood flow. Which finding indicates this improvement?
• Which problem is suggested when a client at 37 weeks' gestation experiences sudden sharp pain in the abdomen with fetal hyperactivity followed by fundal tenderness and a small amount of dark-red bleeding?
• Which color of cerebrospinal fluid (CSF) is considered normal?
• A client with chronic kidney disease is admitted for strict fluid restriction. Which assessment finding requires additional nursing action?
• In a three-tier triage system, which presentation is emergent and should be treated first?
• What percussion note is typically heard over a pneumothorax?
• Which triage level corresponds to a patient with stable vital signs who can have delayed care?
• A triage nurse assigns a red tag to a patient. Which statement best describes this patient's condition?
• Why do burn patients have increased caloric needs?
• In suspected infective endocarditis, which diagnostic procedure should be performed first to identify the causative organism?
• What is the priority nursing intervention for a client on diuretic therapy who has developed metabolic alkalosis?
• An end-stage terminally ill patient has decided to discontinue treatment and has become detached. Which action should the nurse implement first?
• Which component makes seawater hypertonic compared with body fluids?
• The health care provider has determined that a client has irreversible brain damage with subsequent brain death. Organ donation is discussed with the family. Which action should the nurse take prior to contacting the organ procurement organization (OPO)?
• Kehr's sign is best described as referred pain to the left shoulder, suggesting injury to which organ?
• Which tag color indicates a patient who is dead or expected to die in disaster triage?
• A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action?
• In Emergency Severity Index triage, which description best characterizes an ESI-1 patient?
• In bacterial meningitis, the role of glucocorticoids is to:
• Two days after surgical repair of an abdominal aortic aneurysm (AAA), the cardiac monitor shows sinus bradycardia and blood pressure 82/40 mmHg. Nitroprusside is infusing. Which intervention should the nurse implement first?
• Which nursing consideration is appropriate for a 35-week pregnant patient with complete placenta previa?
• Which statement about sarin characteristics is true?
• which drink should be recommended for a burn patient with a potassium level of 6.0 mEq/L (6.0 mmol/L)?
• Which pupillary finding is least likely to be seen with increasing intracranial pressure?
• When a green tag is assigned to a client during disaster triage, which statement is true about the client's injuries?
• What is the highest priority prehospital intervention for a snakebite?
• In a patient on mechanical ventilation, family asks when extubation will occur. Which information should the nurse provide?
• An arterial blood gas shows pH 7.48; PaCO2 50 mmHg; HCO3 27 mEq/L with nasogastric suction. How should the nurse interpret this ABG?
• Which color of cerebrospinal fluid may indicate subarachnoid hemorrhage in the client?
• Brain herniation is manifested by which signs?
• Which clergy member should the nurse contact when a critically ill client requests the Sacrament of the Anointing of the Sick?
• In mass casualty triage, which color tag indicates a patient whose care can be delayed until after more urgent cases?
• After experiencing acute coronary syndrome, a client asks how to tell whether exercise is helping. Which response is most appropriate?
• To support wound healing in a burn patient, which dietary change is most appropriate?
• In the post-anesthesia care unit, a chest tube drainage system is in place after lung surgery. What action should the nurse take?
• Which scenario qualifies as an internal disaster in a hospital setting?
• Which type of shock results from spinal cord or head injury causing vasodilation due to loss of sympathetic tone?
• Which term describes a graft between genetically identical individuals?
• Which Glasgow Coma Scale combination represents the lowest priority for treatment?
• Which scenario best exemplifies primary preventive care?
• Which parameter is not part of the systemic inflammatory response syndrome (SIRS) criteria?
• A client returns to ICU after permanent pacemaker insertion. Which finding should be observed in the immediate hours post-procedure?
• What is the primary goal when educating a patient with primary open-angle glaucoma about treatment?
• A client with gastric ulcers is admitted for cauterization. Which finding should be reported to the healthcare provider?
• What Glasgow Coma Scale score indicates coma?
• Before starting hemodialysis for AKI, which assessment should the nurse obtain?
• In a patient who develops inspiratory stridor after thyroidectomy, what action should the nurse take first?
• During an emergency assessment, rechecking level of consciousness and mental status is part of which assessment component?
• A group of bomb blast victims needs to be transported to the hospital immediately. Which staff members of an emergency unit are most appropriate to handle this situation?
• A client with diabetic ketoacidosis reports abdominal pain and fruity breath; finger-stick glucose reading is too high to register. Which intervention is most important to implement?
• In mass casualty triage, which color tag denotes an immediate life-threatening condition requiring rapid treatment?
• Using the Rule of Nines, what percentage TBSA does the anterior trunk contribute in an adult?
• Which emergency medical service agency offers services for mass fatalities through Disaster Mortuary Operational Response Teams?
• Interpret the ABG result: pH 7.17; PaCO2 70 mmHg; HCO3- 30 mEq/L in a mechanically ventilated patient.
• A client admitted with urosepsis demonstrates systemic inflammatory response syndrome (SIRS). Which of the following findings should the nurse report as meeting SIRS criteria?
• Which laboratory tests should be reviewed for a client with unifocal PVCs thought to be related to electrolyte imbalances?
• A client on a potassium-sparing diuretic has a potassium level of 6.1 mEq/L. Which intervention is appropriate?
• After initial fluid resuscitation in diabetic ketoacidosis, what is the next major treatment step?
• Which system is the overall system for incident management of which HICS is a part, implemented by the Department of Homeland Security and FEMA?
• The client with which color tag would be treated first, according to the disaster triage tagging system?
• Which laboratory tests are commonly used to assess myocardial injury?
• In a client with severe sepsis and respiratory distress, ABG results show pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L. Which assessment finding warrants immediate intervention?
• What is the primary purpose of palliative radiation for a patient with neck cancer in hospice?
• Which ABG pattern best indicates metabolic alkalosis with respiratory compensation?
• A patient with chest pain has ST-segment elevations in leads II, III, aVF and V4R. Which action should the nurse implement first?
• What is the minimum observation period for near-drowning victims in the emergency department?
• In nerve agent exposure like sarin, pralidoxime chloride (2-PAM) dosing is true that:
• In status epilepticus, which medication should be administered immediately?
• In mass casualty triage, which class designation corresponds to emergent status?
• A client burned on the anterior part of both legs from knees to feet. Using the rule of nines, what percentage of total body surface area is burned?
• Crackles heard on auscultation in a patient with severe preeclampsia most likely indicate what?
• Which laboratory tests are most useful to evaluate potential causes of PVCs due to electrolyte imbalance?
• Beck's triad is most indicative of which complication?
• Which condition would take highest priority for a patient in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia?
• In stab wounds, which factors influence the trajectory and depth of injury?
• A client with peaked T waves, widened QRS, and flattened P waves is suspected of severe hyperkalemia. Which medication should be administered?
• Prior to suctioning an intubated patient, which action should the nurse perform first?
• Which rhythm requires immediate defibrillation according to ACLS guidelines?
• During delivery of a neonate from membranes ruptured with pale green amniotic fluid indicating meconium, which action is a priority as the head emerges?
• Which acid-base disturbance is indicated by pH 7.60 with PaCO2 25 and HCO3 24?
• Which electrocardiographic finding is most characteristic of hyperkalemia?
• In a three-tier triage system, which condition is categorized as urgent rather than emergent or non-urgent?
• What information should the nurse provide to facilitate end-of-life discussions for a family caring for a dying client?
• After a client falls from a ladder approximately 15 feet and has a small intracranial bleed, the nurse notes a new onset of left shoulder pain. Which action should be done first?
• Parents of a preterm newborn visit the NICU for the first time. Which response by the nurse most supports parent-infant bonding?
• The ABG pattern with pH 7.37, PaCO2 30, HCO3 28 mEq/L is interpreted as a fully compensated metabolic alkalosis. Which statement is most consistent with this interpretation?
• After a snakebite, what should the nurse do first?
• What does a black tag indicate in mass casualty triage?
• Which triage class would be treated first in a mass-casualty incident?
• In managing a client with bacterial meningitis, what is the priority nursing care?
• Which color-tagged clients usually make up the greatest number in most large-scale multi-casualty situations?
• Which color tag will be given by the triage nurse to a client assigned to class IV during a mass casualty situation?
• When using SBAR to report to the healthcare provider, which statement best supports the nurse's reason for calling?
• Which clinical indicator would suggest increasing intracranial pressure?
• In a patient admitted with pulmonary edema, which clinical finding would you expect on admission assessment?
• In the management of hyperkalemia, what is the purpose of calcium gluconate?
• A patient with type 1 diabetes presents with severe hyperglycemia and symptoms such as weakness and fever; which clinical manifestation should be reported immediately if glucose continues to rise?
• Which statement about pupil changes in increased intracranial pressure is true?
• According to the rule of nines, the anterior surface of one lower limb accounts for what percentage of TBSA?
• A contraction stress test (CST) is positive. Which fetal condition does this most indicate?
• In disaster triage, Class IV patients are those who are
• Which intervention would the nurse anticipate for the newborn of a mother with a long history of diabetes?
• An open fracture with distal pulse would be triaged as which color tag?
• A patient with a demand pacemaker shows a telemetry tracing with a pacing spike but no immediate QRS complex, and the native myocardium elicits a QRS after a delay. What interpretation should the nurse make?
• A chest X-ray is ordered for a patient with suspected ARDS. Which radiographic finding represents progression of pulmonary edema and lung consolidation?
• A patient with cerebral edema after closed head injury is to receive mannitol IV. Which action should the nurse implement when preparing to administer the medication?
• A person on the beach sustains a deep partial-thickness sunburn. Which first-aid measure would you recommend before the client seeks health care?
• Which complication is most closely monitored in abruptio placentae?
• Crush injury from a terrorist explosion is most likely to cause which type of damage?
• In first-degree atrioventricular (AV) block, what is true about the cardiac rhythm?
• Which graft is performed between donors and recipients of the same species but not genetically identical?
• In disaster triage tagging, which tag indicates a patient who can ambulate and does not require immediate treatment?
• In suspected thyroid storm, which action should be performed first to enable treatment?
• In the SBAR communication framework, which component contains the recommended action?
• In a mass casualty incident, which health care professional directs departments to cancel their usual operations to convert space into a minor treatment area?
• In the emergency department triage of a client who is 4 days post-operative laparotomy and reports sudden fever, tremors, decreased orientation, and psychotic behavior, which action should the nurse perform first?
• Which client would be triaged first based on condition?
• Which nursing intervention has the highest priority for a client with a severe neck injury after a motorcycle crash?
• During compensation for an acid-base disorder, what happens to the pH?
• A hypotensive patient is receiving dopamine 10 mcg/kg/min IV through a peripheral line and reports burning at the IV site. Which action should the nurse implement first?
• Which personnel are responsible for identifying the need for and calling in specialty trained providers in emergencies?
• Among four clients admitted at the same time under mass casualty conditions, which client requires the highest priority for treatment?
• Which of the following is a non-modifiable risk factor for myocardial infarction?
• Which healthcare professional serves as the liaison between hospital administration and the media to release only appropriate and accurate information during a mass casualty event?
• What is the highest priority nursing action for a client with a scorpion bite?
• Which client would be triaged under emergency severity index (ESI)-1 based on threat to life and stability of vital functions?
• Which client would be treated first?
• Which condition is the newborn of a diabetic mother especially at risk for immediately after birth?
• Telemetry shows tall, peaked T waves on the waveform in a patient with a post-AV graft. What action should the nurse take first?
• An emergency department patient presents with signs of opioid overdose. Which medication should the nurse administer?
• Which color tag indicates a patient who can wait for treatment (delayed fashion)?
• What is the purpose of the Allen test in the context of arterial blood gas sampling?
• Which type of emergency assessment involves inserting a gastric tube and arranging diagnostic studies after injuries from a bus accident?
• Which blast injury is commonly caused by the shock wave from an explosion?
• Under a three-tiered triage system, which condition would be treated first?
• In mass casualty triage, which injury is triaged under the nonurgent class (class 3)?
• In a mass casualty triage scenario, which color tag is assigned the lowest priority for care?
• Where will the nurse place the V 1 lead when obtaining a 12-lead electrocardiogram?
• Which biological agent associated with terrorism is treated with antitoxin rather than antibiotics?
• In a critical incident stress debriefing team, what is the doorkeeper's primary function?
• What is the primary purpose of the Hospital Incident Command System (HICS) within a hospital during a disaster?
• On the first postoperative day after a kidney transplantation, which intervention should the nurse include to prevent hypovolemia?
• Which client in the emergency department would be seen first by triage?
• Which emergency assessment is performed during the primary survey to evaluate respiratory status?
• Which practice is NOT recommended prior to suctioning an endotracheal tube?
• Which restriction is typical for a patient with complete placenta previa?
• Four hours after a stroke, a client has unequal pupils with one reacting more slowly and the systolic blood pressure is rising. Which condition would require intervention?
• A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and both arms. Using the Rule of Nines, what is total body surface area burned?
• A patient receiving nitroprusside infusion develops bradycardia with hypotension. What is the immediate action?
• In respiratory alkalosis, which of the following is true about PaCO2?
• Which action should the nurse take first before developing a teaching plan for a client who has had a myocardial infarction?
• In mass casualty triage, which color tag corresponds to a patient who can wait for treatment for some time?
• During pharmacologic paralysis with cisatracurium after intracranial hemorrhage, which intervention should the nurse implement?
• Which nursing intervention is most effective in preventing a seizure in severe preeclampsia?
• Which equipment will the nurse prepare for a client whose burn wounds are scheduled to be debrided mechanically?
• The cardiac monitor alarms; the nurse finds a client with no palpable carotid pulse and no spontaneous respirations, with a normal sinus rhythm. Which intervention should the nurse implement first?
• In a mass casualty situation, which is the facility-level organizational model for disaster management used by the hospital or long-term care facility?
• Which pathologic change in ARDS leads to ventilator alarms due to high peak pressures?
• In a mass casualty scenario, which client would be assigned a black tag?
• A patient with a severe burn has an autograft and reports that the edges are curling up. What is the best nurse response?
• Premature ventricular contractions (PVCs) can be associated with electrolyte imbalance. Which electrolyte abnormality is most commonly linked to PVCs?
• In the setting of chest pain treated with nitroglycerin, which finding would most strongly suggest a right ventricular infarction?
• A patient with crushing chest pain receives a sublingual nitroglycerin dose. Minutes later, blood pressure drops from 160/90 to 60/40, and the patient experiences severe nausea, dizziness, and left arm numbness. What is the priority intervention?
• In disaster triage tag system, which description corresponds to class I (needs emergency treatment)?
• Which action represents the highest priority intervention for a trauma patient in the emergency department?
• Before removing an endotracheal tube (extubation), which action should the nurse perform?
• For clients with burns treated using the exposure (open) method, which teaching is essential?
• Which statement justifies keeping the chest drainage system below the chest level?
• The Sacrament of the Anointing of the Sick is one of the seven sacraments in Catholicism.
• Which combination of signs is most indicative of septic shock?
• A patient who survived near-drowning may require observation beyond 23 hours if what condition is present?
• Which scenario is considered secondary acute care?
• What is the normal range for arterial PaCO2?
• Which color of CSF indicates methemoglobin and suggests prior meningeal hemorrhage?
• A patient with a pituitary tumor and diabetes insipidus would need seizure precautions if which electrolyte value is elevated?
• What is the priority action for first responders after a community disaster?
• A rhythm strip shows normal sinus rhythm. Which action is appropriate?
• A mean arterial pressure (MAP) of 57 mmHg indicates what about organ perfusion?
• A woman recently discharged after hysterectomy calls with tenderness, redness, and swelling in the right calf. Which priority action should the nurse instruct the client to take?
• Which statement about red tags is true?
• A client with end-stage COPD on high-flow oxygen has no further treatment available. Which intervention should the nurse recommend as most beneficial to the client and family?
• A trauma patient in the ICU has a Glasgow Coma Scale score of 3, fixed and dilated pupils with no corneal reflex, blood pressure 80/30, and hypothermia. How should the nurse respond to the spouse asking when the client will wake up?
• Which test verifies the correct placement of a pulmonary artery catheter?
• Which action is contraindicated initially in suspected right ventricular infarction?
• Which description best characterizes an ESI-3 patient?
• A patient with SIADH and a serum sodium of 112 mEq/L: what protocol prescription should the nurse implement first?
• Cisatracurium is used to induce paralysis. Which statement about its effect is true?
• Which action of the emergency department nurse caring for a group of clients injured in a community disaster would need correction?
• Which device delivers high-flow oxygen through a nasal cannula up to about 40 L/min and is commonly used in critical care?
• Which parameter of the disability mnemonic AVPU assesses the patient's response to verbal stimuli?
• Which staff members will be the first to manage the care of victims from an accident at the nuclear power plant?
• A patient admitted to the ICU after multiple traumatic injuries has a Glasgow Coma Scale score of 6. Which intervention should the nurse prepare for the client?
• Postoperative thyroidectomy patient develops inspiratory stridor. What action should the nurse take first?
• The nurse is caring for a client scheduled to have a pigskin graft applied to a burned area. About which type of graft is this?
• Which action would the nurse initiate first to ensure the physical safety of a client with severe preeclampsia?
• Which statement about injuries from explosive devices is true?
• Which color tag corresponds to class I during mass casualty triage?
• Which color tag indicates patients who are dead or expected to die?
• Which acid-base disorder is indicated by an arterial blood gas showing pH 7.52, PaCO2 30 mmHg, and HCO3- 28 mEq/L?
• An arterial blood gas shows pH 7.42, PaCO2 50 mmHg, HCO3- 30 mEq/L. How should this ABG be interpreted?
• Which role is responsible for rapidly evaluating each client to determine priorities for treatment during a mass casualty event?
• Two weeks after admission for full-thickness burns, the patient has been losing weight daily. Which dietary adjustment is recommended?
• Applying the emergency severity index criteria, which client condition is considered least severe?
• Which scenario is an external natural disaster?
• In disaster triage color coding, which description corresponds to a green-tagged patient?
• Why isn't monitoring for signs of increased intracranial pressure the priority in bacterial meningitis?
• For a client at 35 weeks' gestation with complete placenta previa in a high-risk prenatal unit, which intervention is a priority to have at the bedside?