HESI Critical Care Exit Hesi 2 Questions and Answers (HESI)

Exam (elaborations) HESI Critical Care Exit Hesi 2 Questions and Answers (HESI) Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes telemetry pattern shows second degree heart block with Ventricular rate of 50. Action Hold scheduled dose and notify HCP of telemetry pattern Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Increased conduction time from the SA node to the AV junction When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on right side only. Action Reposition the depth of the ET tube Nurse called to a train derailment likely caused by terrorist bomb. Triage in order Middle-aged man wandering around Woman sitting on ground with blanket Crying child held by another passenger Mother and father just arrived on scene Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35. Which needs immediate communication to HCP Drowsiness and diff in arousing Assess a 78 year old with L sided HF. Symptoms Dyspnea, cough, fatigue Caring for a burn patient with serum potassium of 4. Question which medication Potassium Patient admitted with deep 2nd degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after burn so nurse expects Decreased cardiac output Patient bedridden for 2 wks with following lab values: pH 7.37, PO2 90, PCO2 40, HCO3 25, hypoalbuminemia and hypocalcemia. Priority action Turn patient side to side q2h Which age group should nurse assess first 40 year old with sickle cell crisis There has been a major disaster. Triage nurse should give which patient priority Cut over eye Move which patient to medical surgical unit Patient with ABNL liver levels One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do Take patient to ICU and arrange for respiratory patient to stay in PACU HESI Critical Care Exit Hesi 2 Questions and Answers Carotid picture Point to neck Someone with wound vac how to make sure it is effective Check seal to make sure no leaks Magnesium antidote Calcium gluconate Patient having trouble swallowing when wife gives drink of water Assess gag reflex OR may have been thickening answer-there were two alike Chest tube becomes disconnected Get new saline bottle to stick end into until reconnect tube Patient in ventricular fibrillation Defib shock once Know calcium levels….there was a question with calcium 5.0 and the answer was patient with hyperthyroidism taking inderal (propanalol) Chest tube volume 125 Mark container between 100 and 150 Heart sounds audio S1S2 Patient on benzos Answer is not narcan ??? Abdominal rigidity 4 patients-which one more concern Low Hgb level 4 patients with conditions of concern-priority Make sure patient has units of blood available Patient on Heparin going for surgery in a.m.,-priority Assess patient for bleeds Patient with fever of 101-best nursing Dx r/t temperature elevation Listening and hearing silence, then kortokoff sound what to do follow through by checking BP Patient with pancreatitis and elevated liver function-what expect of patient patient drinks alcohol daily or lots/wk (alcohol related answer for sure) Patient with dark, tarry stool Sign of GI bleed, pick NSAIDS Patient receiving Morphine in PCA pump Make sure the lock is on the machine Vasopressin Vasoconstrictor Patient comes in with Hx of MRSA put in isolation, get swabs Patient with thick secretions increase fluids Chronic renal failure-S/S Patient would get a black tag during a disaster if he/she exhibited which S/S Know your shocks S/S (hypovolemic, cardiogenic, etc-1 Q for each) 2 RNs must check blood products together before administration Glasgow Coma Scale <8 = coma Myasthenia crisis vs. cholinergic crisis Myasthenia-weakness with change in vitals (give more med) Cholinergic crisis-weakness with no change in vitals (reduce med) Diabetic ketoacidosis Fruity breath Hold Digoxin for HR <60 Stroke Tongue points toward side of lesion (paralysis), uvula deviates away from the side of the lesion (paralysis) Pulmonary air embolus prevention Trendelenburg (HOB down) and on left side to trap air in the right side of the heart Head trauma and seizures Maintain airway is primary concern Hypoventilation Acidosis (too much CO2) Hyperventilation Alkalosis (too little CO2) Cardiac enzymes that you need to know how often to assess after initial CVA Troponin (1 hour), CKMB (2-4 hrs), Myoglobin (1-4 hrs), LDH1 (12-24 hrs) MI treatment Morphine, oxygen, nitro, ASA (NO digoxin, betablockers or atropine for these patients) Ventilators Make sure the alarms are on (Check every 4 hours minimum), when suctioning give 100% O2 before and after and make no more than 3 passes-no longer than 15 seconds Have to put in order of consideration to be delivered Nasal cannula, simple face mask, nonrebreather mask, partial rebreather mask, venturi mask Early signs of cerebral hypoxia Restlessness and irritability Necessary for Blood Product infusions 18-19 gauge needle with filter tubing NS only run with blood within 30 minutes of hanging Check vitals before infusing, at 15 minutes, 30