HESI Advanced Clinical Concepts
Nursing key points for RN NCLEX; ARDS,
Shock, Medications; Medical-Surgical
Nursing; Respiratory system; Renal System -
Dialysis; Cardiovascular System; GI System;
Endocrine SystEM
,
, lOMoARcPSD| 54339004
HESI ADVANCED CLINICAL CONCEPTS an open airway (the allergic reaction damages the lining of the
airways causing edema). Also, keep the client warm without
• ARDS is an unexpected, catastrophic pulmonary complication constricting clothing; keep legs elevated (not Trendelenburg
occurring in a person with no previous pulmonary problems. because the weight of the lower organs restricts breathing).
The mortality rate is high (50%)
• Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
• In ARDS, a common laboratory finding is lowered PO2.
However, these clients are not very responsive to high • Epinephrine: 1:10,000, or 5ml IV for severe
concentrations of oxygen.
• Volume expanding fluids are usually given to clients in shock.
• Think about the physiology of the lungs by remembering However, if the shock is cardiogenic, pulmonary edema may
PEEP: Positive End Expiratory Pressure is the instillation and result.
maintenance of small amounts of air into the alveolar sacs to
prevent them from collapsing each time the client exhales. The • Drugs of choice for shock
amount of pressure can be set with the ventilator and is usually - Digitalis preparations: Increase the contractility of the heart
around 5 to 10 cm of water. muscle
- Vasoconstrictors (Levophed, Dopamine): Generalized
• Suction only when secretions are present. vasonconstriction to provide more available blood to the heart
to help maintain cardiac output.
• Before drawing arterial blood gases from the radial artery,
perform the Allen test to assess collateral circulation. Make • A common volume-expanding substance is plasma and
the client’s hand blanch by obliterating both the radial and possibly whole blood.
ulnar pulses. Then release the pressure over the ulnar artery
only. If flow through the ulnar artery is good, flushing will be • You are caring for a woman who was in severe automobile
seen immediately. The Allen test is then positive, and the accident several days ago. She has several fractures and
radial artery can be used for puncture. If the Allen test is internal injuries. The exploratory laparotomy was successful
negative, repeat on the other arm. If this test is also negative, in controlling the bleeding. However, today you find that this
seek another site for arterial puncture. The Allen test ensures client is bleeding from her incision, short of breath, has a weak
collateral circulation to the hand if thrombosis of the radial thready pulse, has cold and clammy skin, and hematuria.
artery should follow the puncture. - What do you think is wrong with the client, and what would you
expect to do about it?
• If the client does not have O2 to his/her brain, the rest of the - These are typical signs and symptoms of DIC crisis. Expect
injuries do not matter because death will occur. However, they to administer IV heparin to block the formation of thrombin
must be removed from any source of imminent danger, such (Coumadin does not do this). However, the client described is
as a fire. already past the coagulation phase and into the hemorrhagic
phase. Her management would be administration of clotting
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. factors along with palliative treatment of the symptoms as they
arise. (Her prognosis is poor).
• A child in severe distress should be on 100% O2.
NCLEX-RN questions on CPR often deal with prioritization of
• Early signs of shock are agitation and restlessness resulting actions. Question: What actions are required for each of the
from cerebral hypoxia. following situations?
- A 24-year old motorcycle accident vistim with a ruptured artery
• If cardiogenic shock exists with the presence of pulmonary if the leg is pulseless and apneic.
edema, i.e., from pump failure, position client to REDUCE - A 36-year old first time pregnant woman who arrests during
venous return (HIGH FOWLER’s with legs down) in order to labor.
decrease venous return further to the left ventricle. - A 17-year old with no pulse or respirations who is trapped in
an overturned car, which is starting to catch fire.
• Severe shock leads to widespread cellular injury and impairs - A 40-year old businessman who arrests two days after a
the integrity of the capillary membranes. Fluid and osmotic cervical laminectomy.
proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL
cellular level activities ensues. All organs are damaged, and WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
if perfusion problems exist, the damage can be permanent. - The American Heart Association recommends that those with
known angina pectoris seek emergency medical care if chest
• All vasopressors/vasodilator drugs are potent and dangerous pain is NOT relieved by three nitroglycerin tablets 5 minutes
and require weaning on and off. Do not change infusion rates apart over a 150minute period.
simultaneously. - A person with previously unrecognized coronary disease
experiencing chest pain persisting for 2 minutes or longer
• A client is brought into the hospital suffering shock symptoms should seek emergency medical treatment.
as a result of a bee sting. What is the first priority? Maintaining
1
, lOMoARcPSD| 54339004
• It is important for the nurse to stay current with the American fluctuates very little. Therefore, it is a better test of renal
Heart Association’s guidelines for Basic Life Support (BLS) by function than is the BUN. Creatinine is generally used in
being certified every two years as required. conjunction with the BUN test and they normally are in a 1:20
ratio.
• If one rescuer is performing CPR, 1 15:2 ratio of compression - Serum osmolality measures the concentration of particles in a
to ventilations is performed for 4 cycles, then reassess for solution. It refers to the fact that the same amount of solute is
breathing and pulse. If two rescuers are performing CPR, a present, but the amount of solvent (fluid) is decreased.
15:2 ratio is now recommended for compressions to Therefore, the blood can be considered “more concentrated.”
ventilations. Perform for 15 cycles with a 100/min - Urine osmolality and specific gravity increase.
compression rate. When trading off, start with compressions.
• Check the IV tubing container to determine the drip factor
• Initiate CPR with BLS guidelines immediately, then move on because drip factors vary. The most common drip factors are
to Advanced Cardiac Life Support (ACLS) guidelines. 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops
per milliliter.
• When significant arterial acidosis is noted, try to reduce PCO2
by increasing ventilation, which will correct arterial, venous, • Flushing a saline lock requires approximately 1 ½ times the
and tissue acidosis. Bicarbonate may exacerbate acidosis b amount of fluid that the tubing will hold in order to efficiently
producing CO2. Thus, the ACLS guidelines have flush the tubing. REMEMBER to use sterile technique to
recommended bicarbonate NOT be used unless hyperkalemia prevent complications such as infiltration, emboli and infection.
and/or preexisting acidosis is documented.
• A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE
• Infants/prematures may have problems with the following that WITH LIFE.
can predispose to arrest: Beware of the “H’s” – hypoxia,
hypoglycemia, hypothermia, increased H+ (metabolic and/or • The acronym ROME can help you remember: Respiratory,
respiratory acidosis), hypercoagulability (if polycythemia Opposite, Metabolic, Equal.
exists).
• Review the order of blood flow to the heart:
• Changes is osmolarity cause shifts in fluid. The osmolarity of - Unoxygenated blood flows from the superior and inferior vena
the extracellular fluid (ECF) is almost entriely due to sodium. cava into the right atrium, then to the right ventricle. It flows
The osmolarity of intracellular fluid (ICF) is related to many out of the heart through the pulmonary artery, to the lungs for
particles, with potassium being the primary electrolyte. The oxygenation. The pulmonary vein delivers oxygenated blood
pressures in the ECF and the ICF are almost identical. If either back to the left atrium, then to the left ventricle (largest,
ECF or ICF change in concentration, fluid shifts from the area strongest chamber) and out the aorta.
of lesser concentration to the area of greater concentration. - Review the three structures that control the one-way flow of
blood through the heart:
• Dextrose 10% is a hypertonic solution and should be 1. Valves Atrioventricular valves Tricuspid (right side)
administered IV. Mitral (left side)
Semilunar valves Pulmonary (in pulmonary artery)
• Normal saline is an isotonic solution and is used for irrigations, Aortic (in aorta)
such as bladder irrigations or IV flush lines with intermittent IV 2. Cordae Tendinae
medication.
3. Papillary muscles
• Use only isotonic (neutral) solutions in irrigations, infusions,
• Since the T waves represents repolarization of the ventricle,
etc., unless the specific aim is to shift fluid into intracellular or
this is a critical time in the heartbeat. This action represents a
extracellular spaces.
resting and regrouping stage so that the next heartbeat can
occur. If defibrillation occurs during this phase, the heart can
• Potassium imbalances are potentially life-threatening, must be
be thrust into a life-threatening dysrhythmia.
corrected immediately. A low magnesium often accompanies
a low K+, especially with the use of diuretics.
• Observe the client for tolerance of the current rhythm. This
information is the most important data the nurse can collect on
• Fluid Volume Deficit: Dehydration
the client with an arrythmia.
- Elevated BUN: The BUN measures the amount of urea
nitrogen in the blood. Urea is formed in the liver as the end • REMEMBER to monitor the client as well as the machine! If
product of protein metabolism. The BUN is directly related to the EKG monitor shows a severe dysrhythmia, but the client is
the metabolic function of the liver and the excretory function of sitting up quietly watching a TV without any sign of distress,
the kidneys. assess to determine if the leads are attached properly.
- Creatinine, as with BUN, is excreted entirely by the kidneys
and is therefore directly proportional to renal excretory • Marking the operative site is required for procedures involving
function. However, unlike BUN, the creatinine level is affected right/left distinctions, multiple structures (fingers, toes), or
very little by dehydration, malnutrition, or hepatic function. The levels (spinal procedures). Site marking should be done with
daily production of creatinine depends on muscle mass, which the involvement of the client.
2
Nursing key points for RN NCLEX; ARDS,
Shock, Medications; Medical-Surgical
Nursing; Respiratory system; Renal System -
Dialysis; Cardiovascular System; GI System;
Endocrine SystEM
,
, lOMoARcPSD| 54339004
HESI ADVANCED CLINICAL CONCEPTS an open airway (the allergic reaction damages the lining of the
airways causing edema). Also, keep the client warm without
• ARDS is an unexpected, catastrophic pulmonary complication constricting clothing; keep legs elevated (not Trendelenburg
occurring in a person with no previous pulmonary problems. because the weight of the lower organs restricts breathing).
The mortality rate is high (50%)
• Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild
• In ARDS, a common laboratory finding is lowered PO2.
However, these clients are not very responsive to high • Epinephrine: 1:10,000, or 5ml IV for severe
concentrations of oxygen.
• Volume expanding fluids are usually given to clients in shock.
• Think about the physiology of the lungs by remembering However, if the shock is cardiogenic, pulmonary edema may
PEEP: Positive End Expiratory Pressure is the instillation and result.
maintenance of small amounts of air into the alveolar sacs to
prevent them from collapsing each time the client exhales. The • Drugs of choice for shock
amount of pressure can be set with the ventilator and is usually - Digitalis preparations: Increase the contractility of the heart
around 5 to 10 cm of water. muscle
- Vasoconstrictors (Levophed, Dopamine): Generalized
• Suction only when secretions are present. vasonconstriction to provide more available blood to the heart
to help maintain cardiac output.
• Before drawing arterial blood gases from the radial artery,
perform the Allen test to assess collateral circulation. Make • A common volume-expanding substance is plasma and
the client’s hand blanch by obliterating both the radial and possibly whole blood.
ulnar pulses. Then release the pressure over the ulnar artery
only. If flow through the ulnar artery is good, flushing will be • You are caring for a woman who was in severe automobile
seen immediately. The Allen test is then positive, and the accident several days ago. She has several fractures and
radial artery can be used for puncture. If the Allen test is internal injuries. The exploratory laparotomy was successful
negative, repeat on the other arm. If this test is also negative, in controlling the bleeding. However, today you find that this
seek another site for arterial puncture. The Allen test ensures client is bleeding from her incision, short of breath, has a weak
collateral circulation to the hand if thrombosis of the radial thready pulse, has cold and clammy skin, and hematuria.
artery should follow the puncture. - What do you think is wrong with the client, and what would you
expect to do about it?
• If the client does not have O2 to his/her brain, the rest of the - These are typical signs and symptoms of DIC crisis. Expect
injuries do not matter because death will occur. However, they to administer IV heparin to block the formation of thrombin
must be removed from any source of imminent danger, such (Coumadin does not do this). However, the client described is
as a fire. already past the coagulation phase and into the hemorrhagic
phase. Her management would be administration of clotting
• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory failure. factors along with palliative treatment of the symptoms as they
arise. (Her prognosis is poor).
• A child in severe distress should be on 100% O2.
NCLEX-RN questions on CPR often deal with prioritization of
• Early signs of shock are agitation and restlessness resulting actions. Question: What actions are required for each of the
from cerebral hypoxia. following situations?
- A 24-year old motorcycle accident vistim with a ruptured artery
• If cardiogenic shock exists with the presence of pulmonary if the leg is pulseless and apneic.
edema, i.e., from pump failure, position client to REDUCE - A 36-year old first time pregnant woman who arrests during
venous return (HIGH FOWLER’s with legs down) in order to labor.
decrease venous return further to the left ventricle. - A 17-year old with no pulse or respirations who is trapped in
an overturned car, which is starting to catch fire.
• Severe shock leads to widespread cellular injury and impairs - A 40-year old businessman who arrests two days after a
the integrity of the capillary membranes. Fluid and osmotic cervical laminectomy.
proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL
cellular level activities ensues. All organs are damaged, and WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
if perfusion problems exist, the damage can be permanent. - The American Heart Association recommends that those with
known angina pectoris seek emergency medical care if chest
• All vasopressors/vasodilator drugs are potent and dangerous pain is NOT relieved by three nitroglycerin tablets 5 minutes
and require weaning on and off. Do not change infusion rates apart over a 150minute period.
simultaneously. - A person with previously unrecognized coronary disease
experiencing chest pain persisting for 2 minutes or longer
• A client is brought into the hospital suffering shock symptoms should seek emergency medical treatment.
as a result of a bee sting. What is the first priority? Maintaining
1
, lOMoARcPSD| 54339004
• It is important for the nurse to stay current with the American fluctuates very little. Therefore, it is a better test of renal
Heart Association’s guidelines for Basic Life Support (BLS) by function than is the BUN. Creatinine is generally used in
being certified every two years as required. conjunction with the BUN test and they normally are in a 1:20
ratio.
• If one rescuer is performing CPR, 1 15:2 ratio of compression - Serum osmolality measures the concentration of particles in a
to ventilations is performed for 4 cycles, then reassess for solution. It refers to the fact that the same amount of solute is
breathing and pulse. If two rescuers are performing CPR, a present, but the amount of solvent (fluid) is decreased.
15:2 ratio is now recommended for compressions to Therefore, the blood can be considered “more concentrated.”
ventilations. Perform for 15 cycles with a 100/min - Urine osmolality and specific gravity increase.
compression rate. When trading off, start with compressions.
• Check the IV tubing container to determine the drip factor
• Initiate CPR with BLS guidelines immediately, then move on because drip factors vary. The most common drip factors are
to Advanced Cardiac Life Support (ACLS) guidelines. 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops
per milliliter.
• When significant arterial acidosis is noted, try to reduce PCO2
by increasing ventilation, which will correct arterial, venous, • Flushing a saline lock requires approximately 1 ½ times the
and tissue acidosis. Bicarbonate may exacerbate acidosis b amount of fluid that the tubing will hold in order to efficiently
producing CO2. Thus, the ACLS guidelines have flush the tubing. REMEMBER to use sterile technique to
recommended bicarbonate NOT be used unless hyperkalemia prevent complications such as infiltration, emboli and infection.
and/or preexisting acidosis is documented.
• A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE
• Infants/prematures may have problems with the following that WITH LIFE.
can predispose to arrest: Beware of the “H’s” – hypoxia,
hypoglycemia, hypothermia, increased H+ (metabolic and/or • The acronym ROME can help you remember: Respiratory,
respiratory acidosis), hypercoagulability (if polycythemia Opposite, Metabolic, Equal.
exists).
• Review the order of blood flow to the heart:
• Changes is osmolarity cause shifts in fluid. The osmolarity of - Unoxygenated blood flows from the superior and inferior vena
the extracellular fluid (ECF) is almost entriely due to sodium. cava into the right atrium, then to the right ventricle. It flows
The osmolarity of intracellular fluid (ICF) is related to many out of the heart through the pulmonary artery, to the lungs for
particles, with potassium being the primary electrolyte. The oxygenation. The pulmonary vein delivers oxygenated blood
pressures in the ECF and the ICF are almost identical. If either back to the left atrium, then to the left ventricle (largest,
ECF or ICF change in concentration, fluid shifts from the area strongest chamber) and out the aorta.
of lesser concentration to the area of greater concentration. - Review the three structures that control the one-way flow of
blood through the heart:
• Dextrose 10% is a hypertonic solution and should be 1. Valves Atrioventricular valves Tricuspid (right side)
administered IV. Mitral (left side)
Semilunar valves Pulmonary (in pulmonary artery)
• Normal saline is an isotonic solution and is used for irrigations, Aortic (in aorta)
such as bladder irrigations or IV flush lines with intermittent IV 2. Cordae Tendinae
medication.
3. Papillary muscles
• Use only isotonic (neutral) solutions in irrigations, infusions,
• Since the T waves represents repolarization of the ventricle,
etc., unless the specific aim is to shift fluid into intracellular or
this is a critical time in the heartbeat. This action represents a
extracellular spaces.
resting and regrouping stage so that the next heartbeat can
occur. If defibrillation occurs during this phase, the heart can
• Potassium imbalances are potentially life-threatening, must be
be thrust into a life-threatening dysrhythmia.
corrected immediately. A low magnesium often accompanies
a low K+, especially with the use of diuretics.
• Observe the client for tolerance of the current rhythm. This
information is the most important data the nurse can collect on
• Fluid Volume Deficit: Dehydration
the client with an arrythmia.
- Elevated BUN: The BUN measures the amount of urea
nitrogen in the blood. Urea is formed in the liver as the end • REMEMBER to monitor the client as well as the machine! If
product of protein metabolism. The BUN is directly related to the EKG monitor shows a severe dysrhythmia, but the client is
the metabolic function of the liver and the excretory function of sitting up quietly watching a TV without any sign of distress,
the kidneys. assess to determine if the leads are attached properly.
- Creatinine, as with BUN, is excreted entirely by the kidneys
and is therefore directly proportional to renal excretory • Marking the operative site is required for procedures involving
function. However, unlike BUN, the creatinine level is affected right/left distinctions, multiple structures (fingers, toes), or
very little by dehydration, malnutrition, or hepatic function. The levels (spinal procedures). Site marking should be done with
daily production of creatinine depends on muscle mass, which the involvement of the client.
2
