HESI 4 Critical Care MCA 3 Practice Test

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