HESI – Critical Care Adult Health III
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Free HESI – Critical Care Adult Health III Questions
A client who sustained severe liver lacerations in a motorcycle collision is transported to the intensive care unit (ICU) following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from the surgical site. Which action should the nurse take?
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Apply medical antishock trousers (MAST).
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Administer phytonadione.
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Prepare the client to return to the operating room.
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Assist with a diagnostic peritoneal lavage.
Explanation
Correct Answer:
C. Prepare the client to return to the operating room.
Explanation:
Active hemorrhage from the surgical site following a segmental liver resection indicates postoperative bleeding, which is a life-threatening emergency requiring immediate surgical intervention. The nurse should notify the surgical team and prepare the client for an urgent return to the operating room to identify and control the bleeding source. Ongoing blood loss after liver surgery can rapidly lead to hypovolemic shock and coagulopathy, and the only definitive treatment is surgical hemostasis.
Patient Data
History and Physical
A 25-year-old male client is brought to the emergency department (ED) by emergency medical service (EMS) after having a seizure. The client experienced a second seizure while in route to the ED. EMS professional's reports to the emergency department staff that the client has been having a tonic clonic seizure for over 5 minutes. EMS has placed an 18 gauge peripheral IV access device into his right antecubital vein and has 15 L/minute of oxygen being delivered by a nonrebreather mask. No medical history is available for the client at this time.
Nurses' Notes
1400
The client is accepted into the emergency department (ED) from emergency medical services (EMS). The healthcare provider (HCP) is at the client's bedside. The client is having a generalized tonic clonic seizure with no response from outside stimuli.
1405
Lorazepam 4 mg IV push (IVP) given for seizure activity. Tonic clonic movements have stopped. A 12-lead electrocardiogram (ECG) is performed.
1410
Assessment
· Neurological: No response from outside stimuli. Pupils measuring 4 mm in diameter. Emesis and saliva suctioned from oral cavity.
· Cardiovascular: Tachycardiac with thready peripheral pulses.
. Respiratory: Tachypneic with shallow, labored, breathing.
· Gastrointestinal: Within normal limits (WNL).
· Genitourinary: Incontinent of urine.
. Intenumentarv. Warm and flushed
Flow Sheet
1400
Vital signs
. Temperature: 97.2° F (36.2° C), orally
. Heart rate: 132 beats/minute
· Respirations: 32 breaths/minute
· Blood pressure: 167/102 mm Hg
· Oxygen saturation: 87% on a 15 L/minute nonrebreather mask
. Height: 6 ft 1 in (185.42 cm)
· Weight: 175 lb (79.4 kg)
Orders
1405
· Lorazepam 4 mg IV push, give once now
· 12-lead electrocardiogram (ECG)
Imaging Studies
1410
· 12-lead electrocardiogram (ECG): Sinus tachycardia with first degree heart block and tall T waves
Which findings are consistent with acidosis? Select all that apply.
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Warm and flushed skin
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First degree heart block
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Tall T waves
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Shallow, labored breathing
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Thready peripheral pulses
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Incontinent of urine
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Pupils measuring 4 mm in diameter
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No response from outside stimuli
Explanation
Correct Answers:
A, C, D, E
Explanation of Each Correct Answer:
A. Warm and flushed skin:
During acidosis, vasodilation occurs as hydrogen ions accumulate in the bloodstream, leading to warm, flushed skin. This is a compensatory response as the body attempts to increase carbon dioxide (CO₂) removal through peripheral circulation.
C. Tall T waves:
Tall, peaked T waves are a classic sign of hyperkalemia, which commonly develops with metabolic acidosis. In acidosis, hydrogen ions move into cells while potassium shifts out into the bloodstream, resulting in elevated serum potassium levels and characteristic ECG changes.
D. Shallow, labored breathing:
In metabolic acidosis, the body tries to compensate by increasing respiratory effort (Kussmaul respirations) to eliminate CO₂. However, as fatigue sets in, respirations become shallow and labored, worsening the acidosis.
E. Thready peripheral pulses:
Acidosis causes decreased myocardial contractility and vasodilation, which reduce effective tissue perfusion, resulting in weak, thready peripheral pulses. This is often seen as acidosis progresses and cardiac output declines.
A client with hepatic cancer is recovering from a liver resection. What is the most important action for the nurse to include during the immediate post-operative period?
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Assess for hemorrhage.
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Assess for jaundice.
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Measure temperature q4 hours
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Assess for electrolyte imbalances.
Explanation
Correct Answer:
A. Assess for hemorrhage.
Explanation:
During the immediate postoperative period after a liver resection, the greatest risk is hemorrhage due to the liver’s highly vascular nature and the potential for impaired coagulation from decreased hepatic function. The nurse must frequently monitor vital signs, drainage output, and abdominal girth, and assess for signs of hypovolemia or internal bleeding.
Jaundice (B) and electrolyte imbalances (D) may develop later but are not immediate life-threatening concerns. Monitoring temperature (C) is routine but secondary to the priority of detecting postoperative hemorrhage early
During insertion of a pulmonary artery catheter, which action is most important for the nurse to implement?
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Don sterile gloves and hand instruments to the healthcare provider.
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Assess the insertion site for hemorrhage.
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Keep the family informed about the client’s condition.
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Monitor the client for dysrhythmias.
Explanation
Correct Answer:
D. Monitor the client for dysrhythmias.
Explanation:
During pulmonary artery (PA) catheter insertion, the catheter passes through the right atrium and right ventricle before entering the pulmonary artery. As it moves through the heart chambers, it can irritate the myocardium and cause ventricular dysrhythmias, such as premature ventricular contractions (PVCs) or even ventricular tachycardia. Continuous ECG monitoring is essential to detect and respond immediately to these potentially life-threatening rhythm disturbances.
A client with a traumatic head injury and a Glasgow coma scale (GSC) of 7 is intubated and being mechanically ventilated. The head of the bed is raised to 30 degrees and treatment with fentanyl, propofol and mannitol is initiated for increased intracranial pressure. What finding should cause the nurse the most concern at this time?
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Client has no response to painful stimuli.
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Client's blood pressure is 160/72 mmHg.
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Client's urinary output is 300 ml in the last hour.
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Client's blood glucose is 80 mg/dL
Explanation
Correct Answer:
C. Client's urinary output is 300 ml in the last hour.
Explanation:
A urine output of 300 mL in one hour is abnormally high and indicates diabetes insipidus (DI), a complication of traumatic brain injury caused by damage to the posterior pituitary or hypothalamus, leading to a lack of antidiuretic hormone (ADH) secretion. This results in excessive dilute urine output and rapid dehydration, which can worsen intracranial pressure and compromise cerebral perfusion. Immediate intervention is required to correct fluid and electrolyte imbalances and prevent further neurologic deterioration.
A client with a history of herpes and hepatitis presented yesterday to the emergency department (ED) with a fever, headache, and stiff neck. The client was transferred to the intensive care unit (ICU) with a diagnosis of encephalitis. Intravenous fluids of 0.9% normal saline at 125 mL/hour are infusing, and intracranial pressure (ICP) is being monitored. Which assessment finding warrants immediate intervention by the nurse?
Reference Range: Intracranial Pressure (ICP): 7–15 mm Hg
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Average urine output 10 mL/hour
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Moderate sensitivity to light
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Intracranial pressure 10 mm Hg.
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Core body temperature 101.2°F (38.4°C).
Explanation
Correct Answer:
A. Average urine output 10 mL/hour.
Explanation:
A urine output of 10 mL/hour indicates oliguria, which suggests inadequate renal perfusion or possible syndrome of inappropriate antidiuretic hormone secretion (SIADH) — a serious complication of encephalitis and other conditions affecting the brain. SIADH leads to fluid retention, dilutional hyponatremia, and increased intracranial pressure (ICP), all of which can rapidly worsen neurological status. Immediate intervention is necessary to prevent further increases in ICP and neurological deterioration.
The nurse is caring for a client with a T4 spinal cord injury. Which assessment finding should the nurse address immediately?
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Reflexes are absent in the lower extremities.
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Client is incontinent for feces.
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Client's bladder is distended.
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Client has warm, blanching erythema on the sacral area.
Explanation
Correct Answer:
C. Client's bladder is distended.
Explanation:
In a client with a T4 spinal cord injury, a distended bladder can trigger autonomic dysreflexia, a life-threatening emergency characterized by sudden severe hypertension, headache, bradycardia, and possible stroke. The nurse must immediately relieve the bladder distention (e.g., by catheterization) to remove the stimulus.
Absent reflexes (A) and fecal incontinence (B) are expected findings in spinal cord injuries and are not emergencies. Erythema on the sacral area (D) indicates risk for pressure injury but is not immediately life-threatening compared to the danger of autonomic dysreflexia.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
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A nystagmus on the left
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Exophthalmos on the right
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Ptosis on the left eyelid
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Astigmatism on the right.
Explanation
Correct Answer:
C. Ptosis on the left eyelid.
Explanation:
Ptosis refers to the drooping of the upper eyelid, which may partially or completely cover the iris or pupil. It can result from weakness of the levator muscle, cranial nerve III dysfunction, or age-related changes. In this case, the left upper eyelid droops more than the right, so the finding should be documented as ptosis of the left eyelid.
After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I, II, III, aVF, aVL, V5, and V6. Which serum laboratory values are most important for the nurse to monitor?
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Cardiac troponin.
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Creatine kinase-MB (CK-MB).
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Serum glutamic pyruvic transaminase (SGPT).
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Lactate dehydrogenase (LDH).
Explanation
Correct Answer:
A. Cardiac troponin.
Explanation:
The client’s ST-segment elevation in multiple leads is diagnostic of an acute myocardial infarction (STEMI). Following resuscitation and return of spontaneous circulation (ROSC), it is essential to monitor cardiac troponin levels, which are the most specific and sensitive biomarkers for myocardial injury. Elevated troponin levels confirm cardiac muscle damage and help guide ongoing management, including reperfusion therapy, anticoagulation, and cardiac monitoring.
The nurse is caring for a client in the intensive care unit who is mechanically ventilated and sedated following an emergency abdominal aortic aneurysm repair. Which assessment warrants immediate intervention by the nurse?
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Abdominal girth increase of 2 inches.
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Core body temperature of 101° F (38.3° C).
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No spontaneous respirations over set rate.
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Urine output less than fluid intake
Explanation
Correct Answer:
A. Abdominal girth increase of 2 inches.
Explanation:
A rapid increase in abdominal girth after abdominal aortic aneurysm (AAA) repair is a critical finding that may indicate postoperative bleeding, retroperitoneal hemorrhage, or abdominal compartment syndrome. These complications can quickly lead to hemodynamic instability, reduced organ perfusion, and death if not recognized early. The nurse must immediately notify the healthcare provider and prepare for emergency intervention.
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