CRITICAL CARE HESI PRACTICE QUESTIONS AND ANSWERS

The nurse is caring for a client who presents with stroke-like symptoms. The healthcare provider reviews the client's computerized axial tomography (CAT) scan and prescribes recombinant tissue plasminogen activator (rtPA) IV. Which information should the nurse obtain to determine if the client is a candidate for this treatment now? A.) Identify the underlying cause of this condition. B.) Prepare to administer desmopressin (DDAVP). C.) Decrease the intravenous fluids to a maintenance rate. D.) Replace fluid losses with D5W every shift B.) Prepare to administer desmopressin (DDAVP). Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma to the brain such as tumors or injury to the brain in particular the pituitary or hypothalamus area. DI can also occur with cerebral edema present. The antidiuretic hormone deficiency occurs rapidly and results in polyuria, anywhere between 5- 40 liters of urine/24 hours. The client demonstrates signs and symptoms of hypovolemia. Electrolyte imbalances include hypernatremia, along with hypokalemia and hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are primarily controlled through administration of exogenous ADH preparations, of which desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored and fluids are replaced every hour. An intubated client is in the process of being weaned off ventilator support. The client's baseline parameters are temperature 98.2 F (36.8 C), heart rate 88 beats/minute, respirations 14 breaths/minute, blood pressure 112/78 mmHg, and oxygen saturation 94%. Which assessment findings would indicate to the nurse that the client is tolerating the weaning procedure? (Select all that apply.) A.) Oxygen saturation is 91% B.) Slight nasal flaring is present. C.) Heart rate is 97 beats/minute. D.) Work of breathing is done by client E.) Respiratory rate is 36 breaths/minute. A.) Oxygen saturation is 91% C.) Heart rate is 97 beats/minute. D.) Work of breathing is done by client Criteria that indicates a client is tolerating weaning off ventilator support are respirations greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen saturation above 90%; heart rate that does not increase more than 20% from baseline heart rate; most of the work of breathing is performed by the client; and no signs of accessory muscles are used for breathing.