Exam (elaborations) HESI Critical Care Exit Hesi 2 Questions And Answers

Exam (elaborations) HESI Critical Care Exit Hesi 2 Questions And Answers 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 minutes, then every hour, and directly after Checking blood before infusing 2 RNs Check order (expiration date, clots, color, air bubbles, leaks) patient, product, previous transfusion Hx Premedicate with Benadryl for previous rxn What does the PR interval represent Time required for the impulse to travel from atria through the AV node Isotonic solutions D5W NS Lactated ringers Tracheostomy Keep Kelly clamp and obturator at the bedside To assess CVA for hemorrhagic or ischemic CT scan first Heart conditions related to thrombus formation A-fib and A-flutter Aphasia, agraphia, slow, cautious, anxious, memory ok Left hemisphere lesion Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant smile, loss of tonal hearing Right hemisphere lesion Most important indicator of increased ICP Change in LOC Spinal shock Complete loss of all reflexes If the U wave is most prominent what condition hypokalemia Burns First degree- epidermis {superficial} Second degree- epidermis and dermis {deep partial} Third degree- epidermis, dermis, and subQ {full thickness} Pic of patient and description of burns, need to decide what % burned [Rule of 9s- head and neck=9%, UE=9% each, LE=18% each, front trunk=18%, back trunk=18%] 5 Ps of neurovascular status (important with fractures) Pain, pallor, pulse, paresthesia, paralysis S/S of shock Increased pulse and decreased BP S/S of IICP Decreased pulse and increased BP with changes in LOC Suspected Post op bleeding if assess Frequent swallowing, vomiting blood, clearing of throat Primary medications given in ED for respiratory distress Bronchodilators [Sus-phrine (Epinephrine HCI) and Theophylline (Theo-dur)] ABG normals for the following: pH, pCO2, HCO3 pH: 7.35-7.45, pCO2: 34-45 mmHg, HCO3: 22-26 mEq/L Calculation of the heart rate using an EKG rhythm strip count the number of R-R intervals in the 30 large squares and multiply by 10 Intracranial hypertension from a traumatic brain injury is admitted to the trauma unit Elevated head of bed CPR-Arrange in other of priority Establish unresponsiveness Call for help Assess patent airway Assess pt carotid pulses Endometrial carcinoma receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator Wear a dosimeter film badge when in the client’s room 65-year-old female arrives in the ER with shortness of breath and chest pain, nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided The client would not be able to prove malpractice in court Deep vein thrombosis on heparin protocol based on a tPTT of 65 to 95 seconds. The current PTT result is 35 seconds Increase the rate of the heparin infusion Calculate the rate of this rhythm strip (It should be 90-100 depending on which set of 6 squares you use) A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol) Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine (Mucomyst) For increase magnesium level Give calcium gluconate Patient admitted with a Dx of diabetic ketoacidosis (DKA) with scant urinary output, K+2.5 mEq/l, pH of 7.26, T 98ºF, HR 128 bpm, RR 36, and BP 90/52 Pottasium IV at 20 mEq/250 ml over 1 hour Irregular respiratory rate with periods of apnea lasting 10 to 15 seconds Apply supplemental O2 The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85% Administer oxygen by face mask Doing CPR on intubated client with palpable pulse during 2-min cycle of chest compressions, absent breath sounds over left lung prepare for the endotracheal tube to be repositioned Unresponsive client who ingested an unknown number of meperidine (DEMOROL) 50mg tablets. Naloxone (NARCAN) 0.4mg IV is administered, and the client is now responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse Difficulty in arousing Patient in the MICU. What problem is a client probably experiencing who has an easily obliterated radial pulse and below-normal pressures, (BP), (CVP), (PAP), and pulmonary under pressure Hypovolemic shock PRI interval depolarization and repolarization Which is the highest for carcinogenic shock traumatic amputation from the groin down (there one of the choice a pt w/ gunshot wound to the chest and abdomen) *HESI HINT: if Cardiogenic shock exits in the presence of pulmonary edema (ex. from pump failure), position pt to reduce venous return (high fowler’s w/ legs down) in order to reduce further venous return to the left ventricle