Critical Care HESI Latest recent & frequently
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,Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to water
seal. The client is using the incentive spirometer hourly while awake. Which assessment finding warrants
intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness. - correct ans:c) Water seal level 2 cm below the water
seal fill line.
A client with a demand pacemaker has a telemetry tracing with a pacing spike but no corresponding QRS
complex. The client's myocardium is eliciting a QRS after a delay of several seconds. Which telemetry
interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer. - correct ans:a) Loss of capture.
The nurse is caring for a client who underwent surgical repair of the aorta after sustaining injuries in a
fall. Which finding indicates improved blood flow after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50. - correct ans:a) Movement of lower extremities.
The nurse reports findings to the healthcare provider for a client who was admitted to the intensive care
unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report
using the Situation, Background, Assessment, Recommendation (SBAR) format, which statement best
supports the nurse's reason for calling the healthcare provider?
a) Prescription for an additional respiratory treatment.
b) Admission today with difficulty breathing.
c) History of COPD.
, d) Presence of expiratory wheezes in the lower lobes. - correct ans:a) Prescription for an additional
respiratory treatment.
The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation due to
acute respiratory failure. The family asks when the client will be extubated. Which information should
the nurse provide?
a) When the client breathes spontaneously in between mechanical ventilations.
b) Once all serum electrolyte and blood chemistry levels normalize.
c) At the completion of intravenous antibiotic therapy and the infection is resolved.
d) When the chest x-ray shows that the inflammation is resolved. - correct ans:a) When the client
breathes spontaneously in between mechanical ventilations.
The decision to wean a client from mechanical ventilation - correct ans:is based on the client's
spontaneous respiratory rate during trials of interrupted ventilation.
The nurse is caring for a client with severe sepsis related to a ruptured appendix. The client is
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and
labored. Arterial blood gas (ABG) results are: pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24
mmHg. Which assessment finding warrants immediate intervention by the nurse?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds. - correct ans:b) Intercostal muscle retraction.
Intercostal muscle retraction - correct ans:is a critical sign of respiratory muscle fatigue that is likely to
lead to acute respiratory failure, requiring intubation with mechanical ventilation
A client who is hypotensive is receiving an IV infusion of dopamine 10 mcg/kg/minute through a
peripheral line. The client reports burning at the IV site. Which action should the nurse implement?
a) Stop the infusion and notify the healthcare provider of the findings.
b) Check the line for blood return and irrigate the peripheral IV catheter.
c) Apply a cold compress to the site and continue the infusion.
tested exam with comprehensive questions
and verified accurate solution (detailed &
elaborated) GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
CONTACT INFORMATION
WHATAPPSLINK- https://wa.me/254784769540
,Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to water
seal. The client is using the incentive spirometer hourly while awake. Which assessment finding warrants
intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness. - correct ans:c) Water seal level 2 cm below the water
seal fill line.
A client with a demand pacemaker has a telemetry tracing with a pacing spike but no corresponding QRS
complex. The client's myocardium is eliciting a QRS after a delay of several seconds. Which telemetry
interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer. - correct ans:a) Loss of capture.
The nurse is caring for a client who underwent surgical repair of the aorta after sustaining injuries in a
fall. Which finding indicates improved blood flow after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50. - correct ans:a) Movement of lower extremities.
The nurse reports findings to the healthcare provider for a client who was admitted to the intensive care
unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report
using the Situation, Background, Assessment, Recommendation (SBAR) format, which statement best
supports the nurse's reason for calling the healthcare provider?
a) Prescription for an additional respiratory treatment.
b) Admission today with difficulty breathing.
c) History of COPD.
, d) Presence of expiratory wheezes in the lower lobes. - correct ans:a) Prescription for an additional
respiratory treatment.
The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation due to
acute respiratory failure. The family asks when the client will be extubated. Which information should
the nurse provide?
a) When the client breathes spontaneously in between mechanical ventilations.
b) Once all serum electrolyte and blood chemistry levels normalize.
c) At the completion of intravenous antibiotic therapy and the infection is resolved.
d) When the chest x-ray shows that the inflammation is resolved. - correct ans:a) When the client
breathes spontaneously in between mechanical ventilations.
The decision to wean a client from mechanical ventilation - correct ans:is based on the client's
spontaneous respiratory rate during trials of interrupted ventilation.
The nurse is caring for a client with severe sepsis related to a ruptured appendix. The client is
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and
labored. Arterial blood gas (ABG) results are: pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24
mmHg. Which assessment finding warrants immediate intervention by the nurse?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds. - correct ans:b) Intercostal muscle retraction.
Intercostal muscle retraction - correct ans:is a critical sign of respiratory muscle fatigue that is likely to
lead to acute respiratory failure, requiring intubation with mechanical ventilation
A client who is hypotensive is receiving an IV infusion of dopamine 10 mcg/kg/minute through a
peripheral line. The client reports burning at the IV site. Which action should the nurse implement?
a) Stop the infusion and notify the healthcare provider of the findings.
b) Check the line for blood return and irrigate the peripheral IV catheter.
c) Apply a cold compress to the site and continue the infusion.
