Critical Care Exit Hesi

1 - Answer- The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning. 2 - Answer- A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. 4. Ask the client if he knows today's date 3 - Answer- The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?" 4 - Answer- The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain. 3 - Answer- A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back. 2. Elevate the head of the bed 30 degrees. 3. Place the client on her left side with her legs flexed. 4. Place the client supine with the foot of the bed elevated 1 - Answer- A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum