Critical Care HESI - set 2 ,solved with
questions and answers
The nurse calculating fluid resuscitation for young male who was burned in a bloody accident at 12
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noon and is seen in the emergency center at 2 pm. The healthcare provider determines that the client
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
has burns over 30% of his body, mainly on the arms and chest. Using the Parkland formula for fluid
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
resuscitation, the client is to receive 7000 mL of fluid in 24 hours. Which goal should the nurse
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
established for this clients plan of care - ANSW -By 8 pm, the client will have received 3500 mL of fluid
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
When caring for a client on a ventilator, which finding provides the greatest indication that the client
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
has an open airway? - ANSW -Bilateral breath sounds can be auscultating
jk jk jk jk jk jk jk jk jk jk jk jk
The nurse performs a neurological check at the beginning of the shift on a client who was admitted to
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the hospital with a subarachnoid brain attack (stroke). The client's Glasgow coma scale (GCS) is 9.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Which information is most important for the nurse to determine - ANSW -The client's previous GCS
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
score
jk
An adult female with a history of type 1 diabetes mellitus has been vomitting for the past 48 hours and
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which assessment finding
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
warrants immediate intervention by the nurse? - ANSW -excessive thirst
jk jk jk jk jk jk jk jk jk jk
A client is admitted to the intensive care unit (ICU) after a colon resection with a formation of the loop
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
colostomy. The nurse determines that the clients abdominal dressing is clean and dry. Vital signs are
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
heart rate is 130, temperature 101, blood pressure 88/65 mmHg, and urine output 10 mL/hour. Which
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
interventions should the nurse implement? - ANSW -Give a 500 mL IV fluid bolus challenge
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
A client is admitted with a syncopal episodes related to a third-degree heart block. After the placement
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
of a transcutaneous pacemaker, the nurse observes several episodes the pacemaker failure to sense.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
What action should the nurse take? - ANSW -Increase the sensitivity
jk jk jk jk jk jk jk jk jk jk jk
A client is receiving cardiopulmonary resuscitation. After systole is confirmed in two leads and sending
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the transcutaneous pacemaker, which intravenous medication should be administered - ANSW -
jk jk jk jk jk jk jk jk jk jk jk jk
epinephrine (adrenaline) jk
A client has a chest tube connected to a closed water-seal drainage system with suction. What
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
equipment should the nurse always have available at the client's bedside - ANSW -Occulsive dressing
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
(just in case tube comes out)
jk jk jk jk jk jk
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL DS W at 6mL/hour. How many
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
mcg per min of nitroglycerin is infusing? - ANSW -20
jk jk jk jk jk jk jk jk jk jk
Bretylium 1mg/minute via infusion is prescribed for s client and ventricular tachycardia. The available
jk jk jk jk jk jk jk jk jk jk jk jk jk
solution 500 mL DSW contains bretylium 1 gram. The nurse should program the infusion time to
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
deliver how many mL per hour - ANSW -30
jk jk jk jk jk jk jk jk jk
, A client arrives in the emergency department complaining in pain. Which description of pain should
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
prompt the nurse to suspect that it originated in the myocardium? - ANSW -Produces chest heaviness
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
along with left arm pain
jk jk jk jk jk
Four days ago a chest tube was inserted into the second intercostal space of a client who has a
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
pneumothorax. Today the nurse notes that there is no fluctuation in the water-seal chamber of the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Pleuravac. Which intervention would be most appropriate for the nurse to implement? - ANSW -Assess
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the client's breath sounds on the AFFECTED lung
jk jk jk jk jk jk jk jk
In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
recognize that which intervention is essential - ANSW -Encourage the client to breathe deeply and
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
cough at frequent intervals
jk jk jk jk
A postoperative client is admitted to the intensive care unit with an inflated pressure infuser containing
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
a solution of heparin 2 unit/mL attached to a intra material (IA) cannula. Which finding indicates that
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the heparin infusion has achieved its therapeutic use - ANSW -Intra-arterial cannula REMAINS patent
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
The nurse suspects that a client with a central venous catheter in the left subclavian vein experiencing
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
an embolism. What signs and symptoms are most indicative of this condition? - ANSW -Anxiety,
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
confusion, lightheadedness and loss of conciousness
jk jk jk jk jk jk
A female client has been in systole for twenty minutes. She is intubated and epinephrine (adrenaline) 1
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
mg and atropine sulfate 1 mg IV were administered, with no change in the rhythm. Which intervention
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
should the nurse implement? - ANSW -Bring members of the family to a private area to discuss the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
desire to continue life support efforts.
jk jk jk jk jk jk
The nurse is evaluating a client's central venous pressure (CVP) reading that are trending upwards,.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
What nursing diagnoses is supported by the pathophysiological mechanism most likely causing this
jk jk jk jk jk jk jk jk jk jk jk jk jk
increase. - ANSW -Impaired cardiac output
jk jk jk jk jk jk
The high-pressure alarm on a mechanical ventilator is sounding. Which intervention should the nurse
jk jk jk jk jk jk jk jk jk jk jk jk jk
implement immediately? - ANSW -Auscultate bilaterally for breath sounds and conform endotracheal
jk jk jk jk jk jk jk jk jk jk jk jk
suctioning
jk
A client with a history go a vasovagal attacks resulting in Brady-dysrythmias. Which instruction is most
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
important in the teaching plan - ANSW -Use stool softeners regularly
jk jk jk jk jk jk jk jk jk jk jk
The ECG pattern of a client indicates that the cardiac rhythm has changed from first degree to third
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
degree AV block. What intervention should the nurse implement? - ANSW -Assess the client's blood
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
pressure
jk
The nurses caring for a client who hemorrhaged postoperatively and is in the early stage of shock.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Which cardiopulmonary symptoms are most indicative of progression into a stage of shock? - ANSW -
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Increased pulse rate jk jk
Increased systolic pressure jk jk
peripheral extremity mottling jk jk
questions and answers
The nurse calculating fluid resuscitation for young male who was burned in a bloody accident at 12
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
noon and is seen in the emergency center at 2 pm. The healthcare provider determines that the client
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
has burns over 30% of his body, mainly on the arms and chest. Using the Parkland formula for fluid
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
resuscitation, the client is to receive 7000 mL of fluid in 24 hours. Which goal should the nurse
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
established for this clients plan of care - ANSW -By 8 pm, the client will have received 3500 mL of fluid
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
When caring for a client on a ventilator, which finding provides the greatest indication that the client
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
has an open airway? - ANSW -Bilateral breath sounds can be auscultating
jk jk jk jk jk jk jk jk jk jk jk jk
The nurse performs a neurological check at the beginning of the shift on a client who was admitted to
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the hospital with a subarachnoid brain attack (stroke). The client's Glasgow coma scale (GCS) is 9.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Which information is most important for the nurse to determine - ANSW -The client's previous GCS
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
score
jk
An adult female with a history of type 1 diabetes mellitus has been vomitting for the past 48 hours and
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which assessment finding
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
warrants immediate intervention by the nurse? - ANSW -excessive thirst
jk jk jk jk jk jk jk jk jk jk
A client is admitted to the intensive care unit (ICU) after a colon resection with a formation of the loop
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
colostomy. The nurse determines that the clients abdominal dressing is clean and dry. Vital signs are
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
heart rate is 130, temperature 101, blood pressure 88/65 mmHg, and urine output 10 mL/hour. Which
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
interventions should the nurse implement? - ANSW -Give a 500 mL IV fluid bolus challenge
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
A client is admitted with a syncopal episodes related to a third-degree heart block. After the placement
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
of a transcutaneous pacemaker, the nurse observes several episodes the pacemaker failure to sense.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
What action should the nurse take? - ANSW -Increase the sensitivity
jk jk jk jk jk jk jk jk jk jk jk
A client is receiving cardiopulmonary resuscitation. After systole is confirmed in two leads and sending
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the transcutaneous pacemaker, which intravenous medication should be administered - ANSW -
jk jk jk jk jk jk jk jk jk jk jk jk
epinephrine (adrenaline) jk
A client has a chest tube connected to a closed water-seal drainage system with suction. What
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
equipment should the nurse always have available at the client's bedside - ANSW -Occulsive dressing
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
(just in case tube comes out)
jk jk jk jk jk jk
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL DS W at 6mL/hour. How many
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
mcg per min of nitroglycerin is infusing? - ANSW -20
jk jk jk jk jk jk jk jk jk jk
Bretylium 1mg/minute via infusion is prescribed for s client and ventricular tachycardia. The available
jk jk jk jk jk jk jk jk jk jk jk jk jk
solution 500 mL DSW contains bretylium 1 gram. The nurse should program the infusion time to
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
deliver how many mL per hour - ANSW -30
jk jk jk jk jk jk jk jk jk
, A client arrives in the emergency department complaining in pain. Which description of pain should
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
prompt the nurse to suspect that it originated in the myocardium? - ANSW -Produces chest heaviness
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
along with left arm pain
jk jk jk jk jk
Four days ago a chest tube was inserted into the second intercostal space of a client who has a
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
pneumothorax. Today the nurse notes that there is no fluctuation in the water-seal chamber of the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Pleuravac. Which intervention would be most appropriate for the nurse to implement? - ANSW -Assess
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the client's breath sounds on the AFFECTED lung
jk jk jk jk jk jk jk jk
In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
recognize that which intervention is essential - ANSW -Encourage the client to breathe deeply and
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
cough at frequent intervals
jk jk jk jk
A postoperative client is admitted to the intensive care unit with an inflated pressure infuser containing
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
a solution of heparin 2 unit/mL attached to a intra material (IA) cannula. Which finding indicates that
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the heparin infusion has achieved its therapeutic use - ANSW -Intra-arterial cannula REMAINS patent
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
The nurse suspects that a client with a central venous catheter in the left subclavian vein experiencing
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
an embolism. What signs and symptoms are most indicative of this condition? - ANSW -Anxiety,
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
confusion, lightheadedness and loss of conciousness
jk jk jk jk jk jk
A female client has been in systole for twenty minutes. She is intubated and epinephrine (adrenaline) 1
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
mg and atropine sulfate 1 mg IV were administered, with no change in the rhythm. Which intervention
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
should the nurse implement? - ANSW -Bring members of the family to a private area to discuss the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
desire to continue life support efforts.
jk jk jk jk jk jk
The nurse is evaluating a client's central venous pressure (CVP) reading that are trending upwards,.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk
What nursing diagnoses is supported by the pathophysiological mechanism most likely causing this
jk jk jk jk jk jk jk jk jk jk jk jk jk
increase. - ANSW -Impaired cardiac output
jk jk jk jk jk jk
The high-pressure alarm on a mechanical ventilator is sounding. Which intervention should the nurse
jk jk jk jk jk jk jk jk jk jk jk jk jk
implement immediately? - ANSW -Auscultate bilaterally for breath sounds and conform endotracheal
jk jk jk jk jk jk jk jk jk jk jk jk
suctioning
jk
A client with a history go a vasovagal attacks resulting in Brady-dysrythmias. Which instruction is most
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
important in the teaching plan - ANSW -Use stool softeners regularly
jk jk jk jk jk jk jk jk jk jk jk
The ECG pattern of a client indicates that the cardiac rhythm has changed from first degree to third
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
degree AV block. What intervention should the nurse implement? - ANSW -Assess the client's blood
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
pressure
jk
The nurses caring for a client who hemorrhaged postoperatively and is in the early stage of shock.
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Which cardiopulmonary symptoms are most indicative of progression into a stage of shock? - ANSW -
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
Increased pulse rate jk jk
Increased systolic pressure jk jk
peripheral extremity mottling jk jk
