Critical Care Hesi Practice Questions and answers solution - $9.99   Add to cart

Exam (elaborations)

Critical Care Hesi Practice Questions and answers solution

Critical Care Hesi Practice Questions and answers solution 1. What assessment findings should he nurse document in the electronic medical record for a client who is experiencing autonomic dysreflexia after a T-4 spinal cord injury 2. As the nurse is turning a client with a chest tube, the chest tube becomes dislodged from the pleural space. What action should the nurse take first? 3. The nurse plans to administer a low dose prescription for dopamine (Intropin) to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine? 4. The nurse assesses a male client postoperatively who has an arterial line in the radial artery. Assessment findings include pallor, parastesia, and slow capillary refill in the client’s right hand fingers. What action should the nurse plan? 5. A male client is admitted to the cardiac intensive unit with chest pain that began twelve hours ago. The nurse recognizes increased ventricular ectopy? Based on this assessment finding, what actions is most important for the nurse to implement? 6. The nurse is assessing a client who was admitted 24 hours ago to the critical care unit following a motorcycle collision. Which client finding requires intervention by the nurse to reduce the risk for complication related to increased intracranial pressure? 7. A client is receiving cardiopulmonary resuscitation. After asystole is confirmed in two leads and sending for the transcutaneous pacemaker, which intravenous medication should be administered? 8. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow coma scale is 9. What information is most important for the nurse to determine? 9. The healthcare provider prescribes a STAT computerized tomography without contrast for a client who is exhibiting signs of an acute change in the level of consciousness. The nurse is caring for two additional intensive care clients and has an unlicensed assistive personnel assigned to assist with the delivery of care. What action should the nurse take? 10. The healthcare provider prescribes and IV fluid bolus for a client who was admitted two hours ago to the ICU because of adrenal crisis. The client is confused and uncooperative. The nurse has attempted two times to obtain IV access without success. Which intervention should the nurse implement first? 11. Arterial blood gas results indicate that a client with respiratory failure who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm H2O and oxygen concentration of 30%. Which action should help correct the client’s acidosis? 12. An adult present to the emergency department with complaints of epigastric discomfort. The client reports shortness of breath and fatigue for the past two days. Which action should the nurse implement first? 13. The nurse identifies the collaborative problem of potential electrolyte imbalance in a patient with acute pancreatitis. What assessment findings alert the nurse to an electrolyte imbalance associated with acute pancreatitis? 14. A client who sustained severe liver laceration in a motorcycle collision is transported to ICU following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from surgical site. What action should the nurse take? 15. A comatose client requires suctioning q4h. What is the best parameter for the nurse to use to measure the effectiveness of tracheal suctioning? 16. The nurse is assisting the healthcare provider during the insertion of a pulmonary artery (PA) catheter into a client with heart failure. While the PA catheter is advanced the nurse observes the monitor. Which sequence of pressure readings on the hemodynamic monitor indicate the PA is advancing? 17. A male client is admitted to the neurological unit. He has sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse? 18. The nurse is calculating fluid resuscitation for a young adult male who was burned in a boating accident at 12 noon and is seen in the emergency center at 2 pm. The HCP determines that the client has burns over 30% of his body, mainly on the arms and chest. Using the Parkland formula for fluid resuscitation the client is to receive 7, 000 ml of fluids in 24 hours. Which goal should the nurse establish for this client’s plan of care? 19. A male client with an implanted cardioverter/defibrillator reports to the home health nurse that he feels dizzy when the device discharges. What intervention is most important for the nurse to implement? 20. A female client is admitted with a blunt chest injury following a motor vehicle collision. She is confused, hypotensive, cyanotic, and has distant heat sounds. Which nursing assessment finding requires immediate intervention? - 21. 22. After and endotracheal tube is place for a client who requires mechanical ventilation, which intervention should the nurse implement first? 23. A client’s ventilator has indicated progressively higher levels of pressure within the past 3 minutes. The pulse oximeter shows diminishing oxygenation saturation from 97% to 92 % despite the maintenance of all settings: FiO2 of 50 %, IMV 18 and peep 5 cm. The endotracheal tube is correctly place and taped securely. What action should the nurse take? 24. Nitroglycerin 30 mcg/min is prescribed for a client who is admitted with chest pain. Nitroglycerin 100 mg is dispensed in a solution of 250ml of D5W. The nurse should program the infusion pump to deliver how many ml/hr. 25. An elderly client had coronary artery bypass surgery today. Following surgery, the IV infusion pump malfunctioned, and the client inadvertently received a liter of 0.9% normal saline over the past 45 minutes. Which physical assessment is most important for the nurse to make at this time? 26. Two hours after the admission to the ICU following a motorcycle accident that caused chest trauma, the client’s hemodynamic monitors begin to sound alarms. Which assessment findings warrant immediate intervention by the nurse? Select all that apply 27. While admitting a male client with upper extremity, chest, and abdominal burns, the client complains of difficulty swallowing and the nurse observes him drooling. Which intervention should the nurse implement first? 28. The vital signs for a client with heart failure who is admitted to the ICU unit include: temperature 98.6 F, pulse 125 beats/min, respirations 22 breaths/min, and BP/. The nurse determines the client’s central venous pressure and pulmonary artery wedge are elevated. Which intervention should the nurse implement? 29. A female client who had gastric bypass surgery 3 days ago is admitted to the ICU complaining of shortness of breath and chest pain. Her oxygen saturation rate is 88% on 100% non-rebreather. Which intervention should the nurse implement? 30. The nurse is caring for a client on a ventilator notes that the client has asymmetrical chest excursion. What intervention should the nurse implement? 31. A client with end stage liver failure was admitted to the intensive care unit two days ago after three episodes of bloody emesis. No further bloody emesis has occurred since admission. The nurse obtains an order for a liquid diet when the client requests something to eat. Which intervention should the nurse implement? 32. A client arrives in the emergency department via ambulance with injuries from being hit by a bus. Vital signs admission are : BP 126/70 mm Hg, heart rate 100 beats/min, respirations 28 breaths/min, temperature 99 F. Bloody drainage is noted at the client’s left ear canal. What should the nurse do to assess for possible basilar skull fracture and cerebrospinal fluid leak? 33. A client involved in a motor vehicle collision is admitted to the trauma intensive care unit. Which assessment finding warrants immediate intervention by the nurse? 34. A client is brought to the emergency center with a gunshot would with a bullet entry at the level of the last cervical and first thoracic spinal cord (C8 and T1). The client is able to move the upper arms. To further assess the client’s spinal nerve function. What action should the nurse implement? 35. A client is admitted to the ICU with meningitis complicated by syndrome of inappropriate antidiuretic hormone (SIADH). The client is complaining of abdominal cramping and headache. To preventing life threatening seizures, which intervention is most important for the nurse to implement? 36. The nurse is caring for a client who hemorrhaged postoperatively, and is in the early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock? 37. The nurse mixes 200 mg of Dopamine in 50 ml of D5W and plans to administer the solution at a rate of 8 mcg/kg/min to a client weighing 165 pounds. How many ml/hr should the nurse st the infusion pump to administer? 38. A client has a chest tube connected to a closed water seal drainage system with the suction. What equipment should the nurse always have available at the client’s beside? 39. When a client’s mechanical ventilator starts to alarm what is the priority nursing action? 40. The nurse is caring for a client who is experiencing left ventricular failure. Which medication provides the greatest vasodilation effect? 41. A postoperative client is admitted to the ICU with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial cannula. Which finding indicates that the heparin infusion has achieved it therapeutic effect? 42. A client is admitted to the critical unit with third degree complete heart block. A temporary transvenous pacemaker is inserted by the healthcare provider. An hour after pacemaker insertion, this device stops sensing the client’s intrinsic heart rate. Which action should the nurse implement first? 43. I CANT REMEMBER

Preview 2 out of 8  pages

Yongsam

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

Guaranteed quality through customer reviews

Stuvia customers have reviewed more than 450,000 summaries. This how you know that you are buying the best documents.

Quick and easy check-out

Quick and easy check-out

You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.

Focus on what matters

Focus on what matters

Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!

$ 9.99
  • (0)
  Add to cart