Critical Care HESI Exam
1. A client recovering from a percutaneous coronary intervention (PCI)
after an acute myocardial infarction is being transferred from the PACU to
the Cardiac ICU. Which assessment finding should the PACU nurse inform
the healthcare provider of immediately?
a. onset of chest pain
b. need to apply pressure dressing
c. presence of occasional PVCs
d. absence of any urinary output during PACU stay: a. onset of chest pain
This suggests the onset of another MI and reocclusion of a vessel.
2. What is the preferred treatment of an acute MI within 12 hours of
symptom onset?: PCI; places a stent in the affected coronary artery
3. How often must a PCI pressure dressing site be assessed?: q30min
for 4 hours
qh thereafter
4. Central Venous Pressure (CVP): the pressure of blood in the thoracic
vena cava, near the right atrium of the heart; reflects the amount of
blood returning to the heart and the ability of the heart to pump the
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,blood into the arterial system; normal is 2-6 mmHg
5. Sensitivity of a pacemaker: pacing devices ability to detect what
electrical ac- tivity is being generated by the patient's heart to prevent
any competition between the hearts intrinsic activity
6. Contrast Induced Nephropathy (CIN): A sudden deterioration in renal
function that is caused by intravascular administration of iodinated
contrast medium; typi- cally seen with angiplasty/angiography
7. Signs of tension pneumothorax: 1. affected side will have decreased
or ab- sent lung sounds
2. cyanosis
3.Tracheal deviation (late sign)
4. distended neck veins
5. tachycardia, tachypnea
8. Pneumatic Antishock Garment: An inflatable device that covers the
legs and abdomen; used to splint the lower extremities or pelvis, or to
control bleeding in the lower extremities or pelvis.
- used for intraperitoneal hemorrhage
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, 9. What is the expected ABG of a pulmonary embolism?: Tachypnea
and tachycardia--> respiratory alkalosis
10.A client is brought to the emergency department following a motor
vehi- cle accident. Initial assessment reveals that the client is unconscious
with a blood pressure of 165/73 mmHg, HR 50 bpm, RR 8 and irregular,
temperature of 103 F. What do you suspect is happening?: The findings
reveal Cushing's Triad (hypertension with widening pulse pressure,
bradycardia and bradypnea); this indicates increased ICP
11.Symptoms of Right Ventricular Hypertrophy: fatigue, swelling,
weakness, chest pain, SOB, dizziness
12.The nurse is caring for a client who is being weaned from mechanical
ventilation. Which assessment finding indicates that the client is ready
to the the endotracheal tube removed?: - pulse ox: 98% with a T piece
- evidence of reversal of the underlying cause of respiratory failure
-PEEP <8 and FiO2 <0.50
- hemodynamic stability
- ability to initiate an inspiratory effort.
13.A client with ARDS was endotracheally intubated and transferred to the
ICU 12 hours ago. Upon assessment, the nurse notes bilateral rales and
diminished breath sounds in the right middle lobe and bilateral lower
lobes, as well as bluish nail beds. Based on the client's presentation, which
actions should be taken?: - Place the patient in prone position
- administer prescribed Lasix
14.Pulmonary Capillary Wedge Pressure: placed in the pulmonary
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1. A client recovering from a percutaneous coronary intervention (PCI)
after an acute myocardial infarction is being transferred from the PACU to
the Cardiac ICU. Which assessment finding should the PACU nurse inform
the healthcare provider of immediately?
a. onset of chest pain
b. need to apply pressure dressing
c. presence of occasional PVCs
d. absence of any urinary output during PACU stay: a. onset of chest pain
This suggests the onset of another MI and reocclusion of a vessel.
2. What is the preferred treatment of an acute MI within 12 hours of
symptom onset?: PCI; places a stent in the affected coronary artery
3. How often must a PCI pressure dressing site be assessed?: q30min
for 4 hours
qh thereafter
4. Central Venous Pressure (CVP): the pressure of blood in the thoracic
vena cava, near the right atrium of the heart; reflects the amount of
blood returning to the heart and the ability of the heart to pump the
1/
,blood into the arterial system; normal is 2-6 mmHg
5. Sensitivity of a pacemaker: pacing devices ability to detect what
electrical ac- tivity is being generated by the patient's heart to prevent
any competition between the hearts intrinsic activity
6. Contrast Induced Nephropathy (CIN): A sudden deterioration in renal
function that is caused by intravascular administration of iodinated
contrast medium; typi- cally seen with angiplasty/angiography
7. Signs of tension pneumothorax: 1. affected side will have decreased
or ab- sent lung sounds
2. cyanosis
3.Tracheal deviation (late sign)
4. distended neck veins
5. tachycardia, tachypnea
8. Pneumatic Antishock Garment: An inflatable device that covers the
legs and abdomen; used to splint the lower extremities or pelvis, or to
control bleeding in the lower extremities or pelvis.
- used for intraperitoneal hemorrhage
2/
, 9. What is the expected ABG of a pulmonary embolism?: Tachypnea
and tachycardia--> respiratory alkalosis
10.A client is brought to the emergency department following a motor
vehi- cle accident. Initial assessment reveals that the client is unconscious
with a blood pressure of 165/73 mmHg, HR 50 bpm, RR 8 and irregular,
temperature of 103 F. What do you suspect is happening?: The findings
reveal Cushing's Triad (hypertension with widening pulse pressure,
bradycardia and bradypnea); this indicates increased ICP
11.Symptoms of Right Ventricular Hypertrophy: fatigue, swelling,
weakness, chest pain, SOB, dizziness
12.The nurse is caring for a client who is being weaned from mechanical
ventilation. Which assessment finding indicates that the client is ready
to the the endotracheal tube removed?: - pulse ox: 98% with a T piece
- evidence of reversal of the underlying cause of respiratory failure
-PEEP <8 and FiO2 <0.50
- hemodynamic stability
- ability to initiate an inspiratory effort.
13.A client with ARDS was endotracheally intubated and transferred to the
ICU 12 hours ago. Upon assessment, the nurse notes bilateral rales and
diminished breath sounds in the right middle lobe and bilateral lower
lobes, as well as bluish nail beds. Based on the client's presentation, which
actions should be taken?: - Place the patient in prone position
- administer prescribed Lasix
14.Pulmonary Capillary Wedge Pressure: placed in the pulmonary
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