HESI Critical Care Exam with 100% Correct Answers 2023/2024

How to calculate HR on EKG - Correct Answer-big boxes: take 300 and divide by the number of boxes between RR Atrial Fibrillation - Correct Answer-Rapid, random, ineffective *contractions of the atrium* No P Waves, *Normal QRS w/ irreg intervals* Risk for thrombi Tx: anti coagulants (Heparin), TEE, Synchronized Cardioversion Atrial Flutter - Correct Answer-No P Waves, QRS at reg intervals Sawtooth or FLUTTER WAVES Tx: Anti coagulants, TEE, synchronized cardioversion Adenosine, beta blockers, calcium channel blockers, digitalis (digoxin) (Fluttering in a circle singing "ABCDs") Supraventricular Tachycardia (SVT) - Correct Answer-Episodes of abnormally fast/racing heartbeat (between 150-250) Normal QRS w/ reg intervals Tx: first - valsalva's maneuver, carotid massage, ice to face *Adenosine*, beta blockers, calcium channel blockers, dig Premature Atrial Complexes (PAC) - Correct Answer-stimulus can be caffeine, nicotine, alcohol stress common but if pt has cardiac probs it can cause ischemia usually asymptomatic tx: take away trigger Ventricular Tachycardia (V-tach) - Correct Answer-Can deteriorate to V Fib Tx: check pulse and LOC... if they have a pulse: synchronized cardioversion Vasopressin, Lidocaine, Amiodarone, Magnesium, Epi (V TACH = V LAME) if pulseless = CPR and defibrillation 3 or more PVCs in a row - Correct Answer-V-tach Ventricular Fibrillation (V-fib) - Correct Answer-abnormal heart rhythm which results in quivering of ventricles *FATAL RHYTHM* Tx: *Defibrillation*, CPR Asystole - Correct Answer-no electrical impulses unconscious and pulseless *DO NOT START CPR UNTIL YOU CHECK TWO LEADS* TX: CPR, epi or vasopressin Cardioversion - Correct Answer-- Elective procedure (informed consent is needed) - Synchronized with QRS - *50-100* Joules Defribrillation - Correct Answer-- Emergency (call code) - V-fib / V-Tach - Begin with 200 joules (can go up to 300) - No CO - Synch off - Make sure O2 is shut off before starting to avoid fire! - No one can touch bed First Degree AV Block - Correct Answer-- Prolonged PR interval - Pt usually asymptomatic - tx: nothing, not fatal Second Degree AV Block Type 1 (Wenckebach) - Correct Answer-PR lengthens progressively then drops a QRS complex (longer... longer... longer, drop = Wenckebach usually benign tx: monitor if symptomatic or HR < 60 Second Degree AV Block Type 2 (Mobitz) - Correct Answer-PR interval is constant then drops QRS can progress to third degree AV block and asystole tx: temp pacemaker and then permanent pacemaker Atropine, Epi, Dopamine Third degree AV Block (complete heart block) - Correct Answer-- atria and ventricles contract independently (Atria 60-100 bpm; ventricles 24-40) - can progress to V. Fib (bad) tx: pacemaker, atropine, epi, dopamine Hold Digoxin - Correct Answer-HR < 60 Low K+ = risk for ______ toxicity - Correct Answer-Digoxin Pad Placement for Defib or Cardioversion - Correct Answer-one pad is placed at the third intercostal space to the right of the sternum the other is placed a the fifth intercostal space on the left midaxillary line CPR (cardiopulmonary resuscitation) - Correct Answer-CAB: compressions - airway - breathing check pulses for <10 secs depth: 2 in rate: 100-120 compressions per min 30 compressions: 2 breaths Glasgow Coma Scale (GCS) - Correct Answer-LOC Assessment eye opening (4), verbal response (5), motor response (6) <8 = intubate!! Early signs of increased ICP - Correct Answer-Decreased LOC Late signs of increased ICP - Correct Answer-- Cushing's triad (1- widened pulse pressure, 2- bradycardia w/ bounding pulse, 3- slow, irregular respiration) - pupil changes - elevated temp - resp changes - abnormal posturing Treatment of ICP - Correct Answer-goal to keep ICP <20 mannitol diuretics controlled hyperventilation avoid narcotics keep head in neutral position Basilar Skull Fracture - Correct Answer-Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis). + halo nasal/ ear drainage Brown Recluse Bite Care - Correct Answer-apply ice immediately and intermittently for up to 4 days (decreases enzyme activity of venom and risk of necrosis) Black Widow Spider Bite Care - Correct Answer-(bite will cause small, red papule; venom is neurotoxic) ice applied immediately! Tarantula Bite Care - Correct Answer-(spider launches its hair into skin and causes inflammatory action) - remove hair ASAP with sticky tape, throughly irrigate the skin, saline irrigation for eye exposure - elevate involved extremity and immobilize - antihistamines and corticosteroids are necessary - tetanus shot Snake Bite Care - Correct Answer-- immediately move victim away from area and try to calm them down - extremity is immobilized and kept BELOW level of the heart - constricting clothing and jewelry should be removed - victim should be kept warm and avoid alcoholic or caffeinated beverages - if unable to seek emergency med attn promptly a constricting band should be placed proximal to the wound (loosen band if edema occurs) - the wound should NOT be incised or sucked to remove venom and ice should NOT be placed - anti-venom may be administered along with supportive care For all Poisonous Bites - Correct Answer-the Poison Control Center should be called ASAP to determine best initial management Poison ivy, Oak, Sumac care - Correct Answer-- cleanse skin ASAP - apply cool, wet compresses to relieve itching Frost Bite Care - Correct Answer-- rewarm rapidly and continuously with warm water or towels at 104 to 107.6 degree F (may be painful, analgesics may help) - immobilize area - avoid using dry heat and never rub area - avoid compression - loose and non-adherent sterile dressings may be applied - monitor for signs of compartment syndrome - tetanus prophylaxis is necessary Burn Care- Primary Goals - Correct Answer-- maintain patent airway - administer IV fluids - preserve vital function - avoid hypovolemic shock Priority Nursing Actions for Burn Patients - Correct Answer-1) assess for airway patency 2) admin O2 as prescribed 3) obtain vitals 4) initiate IV line and begin fluid replacement 5) elevate extremities if no fractures are present 6) keep pt warm and NPO status Superficial Thickness Burn - Correct Answer-- injury to epidermis. mild to severe erythema is noted, and the skin blanches with pressure. - Painful - pain is eased by cooling - discomfort lasts about 48 hrs - healing occurs in about 3-6 days - no scarring or skin grafts required Superficial Partial Thickness Burn - Correct Answer-Involves the epidermis and the upper portion of the dermis. Involved area may be extremely painful and sensitive to air exhibit blisters and edema wet shiny weeping appearance Deep Partial Thickness Burn - Correct Answer-- extends deeper into the dermis - blisters may or may not form - red, dry and white areas in deeper parts - can convert to full thickness if tissue damage increases with infection, hypoxia or ischemia - Deep Full Thickness Burn - Correct Answer-- destruction of both epidermis and dermis - no blisters present - appears dry, hard and leathery - waxy, white, deep red, yellow, brown or black - sensation is reduced Full Thickness Burn - Correct Answer-- extends to muscles, bones, tendons - appears black and sensation is completely absent 100% Occlusion of Right Artery - Correct Answer-causes decreased perfusion of myocardial tissue inadequate myocardial O2 supply hypertension angina dysrhythmias risk of MI heart failure syncope ABGs- Check while - Correct Answer-tracheal suctioning you'll know if they have benefited from it if ABGs are WNL DKA Tx: Potassium - Correct Answer-at the time of admission pt will be hyperkalemic (bc they are acidotic) during treatment for DKA insulin will cause potassium to go into the cell which will cause hypoK+ (signs confusion, lethargy and irregular pulse) CVP (central venous pressure) - Correct Answer-2-6 mmHg low - hypovolemia and require fluids high - hypervolemia, HF = diuretics and digoxin Implantable Cardioverter Defibrillator (ICD) - Correct Answer-- wear medic alert bracelet - DO NOT wear tight clothing over insertion site - avoid contact sports and heavy lifting for 2 months after insertion - weakness and dizziness = device has discharged and corrected a potentially lethal dysrhythmia HHNS- Goals of Care - Correct Answer-- correct fluid imbalance - correcting electrolyte imbalance - lower blood glucose levels with insulin - treating underlying condition Cushing's Triad - Correct Answer-irregular breathing, widened pulse pressure (or hypertension), and bradycardia signs of increased ICP and risk for brain herniation once this happens Warfarin Doses - Correct Answer-A djusted to maintain the INR between 2.0-3.0 After providing the first shock to the client in V fib - Correct Answer-CPR should be done assess the rhythm 2 min after CPR was started Assessment findings that indicate an air embolism - Correct Answer-dyspnea tachypnea cyanosis hypotension chest pain Beck's Triad for Cardiac Tamponade. - Correct Answer-(1) HYPOTENSION (2) MUFFLED or DISTANT HEART SOUNDS (3) JUGULAR VENOUS DISTENSION (JVD) / increased CVP ***Physical Exam: Tachycardia, Hypotension+++, PULSUS PARADOXUS (↓ in systolic BP on inspiration >10mm Hg). Tx: PERICARDIOCENTESIS MAP (mean arterial pressure) - Correct Answer-The average pressure for the entire cardiac cycle 60 is required to diffuse all organs (below would indicate need for fluids and if fluids do not work then vasopressor therapy is indicated) If after suctioning a client there is still no improvement in O2 sat what should be done? - Correct Answer-assess vital signs As the PA catheter passes through the RV into the Pulmonary Artery (PA) what changes occur in the wave form? - Correct Answer-the tip of the cath may irritate the ventricle and cause PVC (these should stop once the catheter is advanced into the PA) What should the arterial blood Carbon Dioxide level goal be for a client with increased ICP - Correct Answer-35-45 mm/hg PEEP - Correct Answer-ventilator setting that can be used to ensure that the airway pressure at the end of expiration remains higher than the atmospheric pressure. This prevents the airway from collapsing! high PEEP is often needed in clients with ARDs to improve O2 and lung ventilation Complications associated with high PEEP - Correct Answer-- barotrauma (may result in pneumothorax) - increase in intrathoracic pressure = decrease in central venous return and CO *any sign of decreased CO (decreased UO), absent breath sounds, asymmetric wall expansion, hypotension, tachycardia should be a concern after increasing PEEP* Serum Amylase in Acute Pancreatitis - Correct Answer-will rise within 2-12 hours of onset but with treatment it will take 3-4 days to return to normal Neurogenic shock - Correct Answer-above T6 injuries Spinal shock - Correct Answer-loss of all motor, sensory, and reflex activity at the level of the injury and below - return of the perianal reflex indicates the resolution of spinal shcok Late signs of septic shock - Correct Answer-lethargy oliguria rapid slow respirations Nitroglycerin - Correct Answer-should be diluted in a glass bottle Beta Blocker admin - Correct Answer-IVP over 2-3 min After ETT placed - Correct Answer-the position of the tube should be verified first via chest xray after the client has been on a ventilator for 30 min ABGs should be evaluated Goal for client with PE - Correct Answer-1) adequate O2 2) begin anticoagulant therapy (monitor for bleeding and clotting times) Undersensing (pacemaker) - Correct Answer-pacemaker fails to sense the intrinsic beat and delivers a pacing artifact into the ST segment of the intrinsic beat Failure to capture (pacemaker) - Correct Answer-noted when pacing artifact is present without depolarization and is seen on the rhythm strip as pacing artifact with no paced beat Parkland Formula - Correct Answer-4mg/ kg of body weight, and first half within the first 8 hours SVT treatment - Correct Answer--vagal stimulation: Valsalva maneuver, carotid massage -IV adenosine is drug of choice Central Venous Pressure (CVP) - Correct Answer-below normal or indicative of venodilation (postural hypotension, tachycardia, decreased MAP) upward assessment = fluid volume overload, hypertension, right ventricular failure Addisonian crisis - Correct Answer-acute adrenal insufficiency precipitated by stress, infection, trauma, surgery, may cause hypoNa+, hyperK+, hypoglycemia, and shock s/s: severe HA ab, leg and back pain weakness irritability and confusion sever *hypotension* shock *interventions* prepare admin of glucocorticosteroids IV fluids Thyroid Storm - Correct Answer-increased temp tachycardia systolic hypertension n/v/d agitation, tremors, anxiety irritability, agitation, restlessness, confusion, seizures delirium and coma Thyroid Storm Causes - Correct Answer-- uncontrolled hyperthyroidism - manipulation of thyroid gland during surgery - severe stress and infection Thyroid Storm treatment? - Correct Answer-maintain airway and adequate ventilation admin antithyroid meds, iodines, propranolol, and glucocorticosteriods monitor vital signs monitor for dysrhythmias administer nonASA antipyretics use cooling blanket Post-Thyroidectomy - Correct Answer-semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypoparathyroidism - Correct Answer-can occur post thyroidectomy s/s hypoCa+, hyperPhosphate +trousseaus and chvosteks signs hypotension anxiety, irritability, depression Following hypophysectomy - Correct Answer-monitor and report post nasal drip or clear nasal drainage which could indicate that cerebral spinal fluid is leaking CSF should be tested for glucose levels DKA treatment - Correct Answer-- start with rapid IV infusion of .9% NS or .45% NS - dextrose may be added when BG falls to 250 to 300 - risk for cerebral edema when there is a rapid change in glucose, fluid or electrolyte levels - insulin IV as prescribed - K+ replacement may be needed if hypoKalemia occurs after fluid and insulin and admin) - cardiac monitoring should be in place Paracentesis Nursing Care - Correct Answer-position upright monitor blood pressure and HR closely Purple-black stoma indicates what? - Correct Answer-- indicates compromised circulation - requires immediate health care provider notification Pneumothorax - Correct Answer-air in the pleural cavity s/s: absent breath sounds on affected side, cyanosis, decreased chest expansion unilaterally, hypotension, dyspnea, chest pain, deviated trachea, tachycardia, tachypnea ARDS Assessment Findings - Correct Answer-tachypnea, dyspnea, decreased breath sounds, deteriorating ABG levels (resp acidosis, hypoxemia), *hypoxemia despite O2 delivery*, decreased pulmonary compliance, pulmonary infiltrates Acute Asthma Episode - Correct Answer-Nursing Interventions: - high fowlers - administer O2 as prescribed - stay with the client - administer bronchodilators (albuterol) - administer corticosteroids - auscultate lung sounds before, after and during treatment Pulmonary Emoblism (PE) - Correct Answer-- caused by prolonged immobilization, surgery, those at risk for DVT - fat emboli can occur after fracture of long bone s/s: dyspnea, apprehension, cough, hemoptysis, tachypnea, feeling of impending doom - notify rapid response team - reassure the client an elevate the head of bed - prepare to admin O2 - obtain vitals and check lung sounds - prepare for admin of anticoagulants - document the event Sinus Bradycardia Treatment - Correct Answer-atropine (will increase the HR) Spinal Cord Injury - Correct Answer-Nursing interventions are focused on stabilization of the spine, preserving the airway and respiratory status and preventing complications associate with SCI. Assessment of respiratory and neurological status is first priority, might need to be tubed. If in neurogenic shock, they cannot regulate body temperature ICD teaching - Correct Answer-site care and symptoms of complications, hematoma at the site is common, wear a medic alert bracelet, when device fires the patient will feel either tingling or discomfort or wont even know it went off. avoid strong magnetic fields (MRI), keep cell phones 6 inches from ICD, may fire when tachycardic, avoid driving for 6 months if hx of cardiac arrest, teach family CPR Ventilator Alarms - Correct Answer-can be caused by biting tube, kinks, need suctioned or trying to talk ARDS and Lung Trauma - Correct Answer-Refractory hypoxemia: hallmark sign of ARDS. FiO2 could be 100% but Pao2 is <60%. only intervention is ECMO which is difficult because adults need anticoagulation therapy. Bilateral patchy infiltrates: patches of white on a lung x ray Noncompliance of the lung: it will not expand, need to be sedated -initial ABGs show low CO2 because of hypervention then it flips to metabolic acidosis - lungs clamp down so it is difficult to breath, capillary membrane damage) Treatment: ventilator, lung protective strategies (low TV, FiO2 at nontoxic levels ~60%, unconventional vent settings i.e. RR 300-420 BPM) VAP - Correct Answer-main cause is aspiration, poor oral hygiene, contaminated equipment. strategies to reduce VAP: - elevated HOB 30-45 degrees, hand hygiene and gloves when suctioning, suction above cuff before deflation, oral hygiene Q2!!!! Documentation of Pneumothorax Breath Sounds - Correct Answer-they are absent Tension Pneumothorax and Trauma - Correct Answer-tension pneumo can be caused by mechanical ventilation. pressurized air enters the pleural space and continues to accumulate which causes an increase in pressure, increasing amount of alveoli collapse and pressure on the heart and great veins. immediate insertion of a chest tube is needed and removed from vent Chest Tube Assessment - Correct Answer-splint insertion site to facilitate coughing and deep breathing. do not milk the tube, do not clamp the tube Mechanical Ventilator and Respiratory Acidosis - Correct Answer-If the ventilator is set at a low RR (e.g., 2 to 6 breaths per minute) and the patient does not have an adequate drive to initiate additional breaths, respiratory acidosis may occur. Ideally the VT and RR are set to achieve a VE that ensure a normal PaCO2 level PE- First Action - Correct Answer-anticoagulation with heparin. venous preventions-- is NOT oxygen first, anticoag first Patient safety and ICU confusion - Correct Answer-Acute delirium is common in critically ill patients; more than 70% to 80% of patients develop some form of delirium, resulting in longer duration of mechanical ventilation and longer ICU stay than those without delirium. Non restraints and pharmacologic measures are taken first. If pulling at drains then they may be restrained. Haloperidol is the drug of choice to calm patients Restraint Intervention - Correct Answer-must be repositioned, and the areas where the restraints are applied are assessed for perfusion and sensation at least every hour Aortic Aneurysm Repair - Correct Answer-Post op: VS Q1 hour (watch for tachycardia and hypotension). Peripheral pulses. Monitor for hemorrhage. CHF and Hemodynamic Readings - Correct Answer-Mixed venous oxygen saturation, stroke index, cardiac index, and pulmonary artery pressures ***PCWP/ pulmonary diastolic will be elevated Primacore - Correct Answer-medications for CHF/shock/renal failure. it helps tissue perfusion Primacore- Side Effects - Correct Answer-increases HR ventricular ectopy hypotension if it infiltrates it causes necrosis (be sure to use large vein to infuse) PTCA post op management - Correct Answer-watch groin for bleeding and check distal pulses Air Embolism - Correct Answer-Nursing Intervention- Position patient in trendelenberg on left side (left lateral) give high FiO2 (100%) to decrease ischemia Antiarrhythmis protocol - Correct Answer-Amiodarone: 1st drug for pulseless Vtach -Lidocaine: if cannot give amiodarone (VF, VT, PVC) Epinepherine: given if unresponsive to CPR (can go down ETT) Atropine: increases HR, SVR, BP Dopamine: given if hypotensive not caused by hypovolemia Adenosine: SVT Sodium bicarb: last ditch effort if everything fails calcium choride: hyperkalemia, hypocalcemia Magnesium: Torsades ***drugs down ETT: LEAN (Lidocaine, Epinepherine, Atropine, Narcan) ***Phentolamine given for infiltrated area Hemodynamic Normal Values - Correct Answer-CO: 4-8 CI: 1.5-2.0 for cardiogenic shock (<1.5 irreversible) Pulmonary artery BP: 15-30/4-12 PCWP: 6-12 (12-18 for optimal contraction) Dopamine Drip - Correct Answer-given if patient is hypotensive but not hypovolemic. started at 2-5 mg/kg/hr then titrated up based on response can cause MI, dysrhythmias like tachycardia and PVC Can cause severe infiltration. Give Phentolamine to help area Sepsis - Correct Answer-VAP is common infection that causes sepsis Before antibiotics are started, the source of infection must be identified, C&S. S/S include: chills or fever, low BP, tachycardic, shakiness, hyperglycemia and/or insulin resistance ****decreased SVR, flushing, oliguria!!!! Common cause of SIRS and MODS Septic Shock and Dopamine - Correct Answer-do not give dopamine until fluids are replaced Thrombolytics - Correct Answer-could be used for someone who cannot go to cath lab they use thrombolytics instead. - reperfusion (drug was successful) for LAD lesion patient when they are bradycardic and chest pain is no more Nitroglycerin and Nipride - Correct Answer-vasodilators. Do not give if BP is low. watch for toxicity AAA Physical Assessment - Correct Answer-sudden severe chest pain is most common sign or pain between the scapulae. systolic BP might be different if taken in each arm. Paresthesias Trauma and Emergency - Correct Answer-Evaluation of airway patency, ventilation, and venous access with circulatory support are of prime importance and take precedence over other diagnostic or definitive interventions. ABCDE (airway, breathing, circulation, disability (glascow coma score), expose patient) Shock (hypovolemia) first aide - Correct Answer-give fluids first For every 1 cc of blood loss, need 3 cc of crystalloids or blood Allergy Assessment before angioplasty - Correct Answer-IV dye or shellfish