CRITICAL CARE RN HESI EXIT ACTUAL |!| |!| |!| |!| |!| |!|
EXAM TEST BANK LATEST EXAM |!| |!| |!| |!| |!|
QUESTIONS WITH VERIFIED DETAILED |!| |!| |!| |!|
ANSWERS
The nurses calculating fluid resuscitation for young adult male who was
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
burned in a bloody accident at 1200 and is seen in the ER at 1400. The
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
HCP determines that the client has burn over 30% of his body, mainly over
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
his arms and chest. Using the Parkland formula for fluid resuscitation, the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
client is to receive 7000 mL of fluid in 24 hours. Which goal should the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
nurse establish for this clients plan of care? - correct answer✔✔By 2000,
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the client will have received 3500 mL of fluid
|!| |!| |!| |!| |!| |!| |!| |!|
When caring for a client on a vent, which finding provides the greatest
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
indication that the client has an open airway? - correct answer✔✔Bilateral
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
breath sounds can be auscultated |!| |!| |!| |!|
The nurse performs a prescribed a neurological check at the beginning of
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the shift on a client who was admitted with a subarachnoid brain attack
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
(Stroke). The client's GCS is 9. What information is most important for the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
nurse to determine? - correct answer✔✔The client's previous GCS score
|!| |!| |!| |!| |!| |!| |!| |!| |!|
An adult female with a history of type 1 diabetes has been vomiting for
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the past 48 hours and is admitted to the ICU with DKA. Which assessment
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
finding warrants immediate intervention by the nurse? - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔Excessive thirst |!|
A client admitted to the ICU after a colon resection with the formation of
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the loop colostomy. The nurse determines that the clients abdominal
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
dressing is clean and dry. Vital signs are: HR: 130, temperature: 100, BP:
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
, 88/65, and urine output of 10 mL/hr. What interventions should the nurse
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
implement? - correct answer✔✔Give a 500 mL IV fluid bolus challenge |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
A client is admitted with syncopal episodes related to a third degree heart
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
block. After the placement of a transcutaneous pacemaker, the nurse
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
observes several episodes the pacemaker failure to sense. What action
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
should the nurse take? - correct answer✔✔Increase the sensitivity
|!| |!| |!| |!| |!| |!| |!| |!|
A client is receiving CPR. After systole is confirmed in two leads and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
sending the transcutaneous pacemaker, which IV medication should be
|!| |!| |!| |!| |!| |!| |!| |!| |!|
administered? - correct answer✔✔Epinephrine (adrenaline) |!| |!| |!| |!|
A client has a chest tube connected to a closed water seal drainage
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
system with suction. What equipment should the nurse always have
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
available at the clients bedside? - correct answer✔✔Occlusive dressing
|!| |!| |!| |!| |!| |!| |!| |!|
Bretylium 1 mg/min via infusion is prescribed for a client and ventricular
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
tachycardia. The available solution is 500 mL D5W contains bretylium 1 |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
gram. The nurse should program the infusion time to deliver how many
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
mL/hr? - correct answer✔✔30 |!| |!| |!|
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
D5W at 6 mL/hr. How many mcg/min of nitroglycerin is infusing? - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔20
A client arrives in the ER complaining of pain. What description of pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
should prompt the nurse to suspect it originated in the myocardium? -
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
correct answer✔✔Produces chest heaviness with left arm pain
|!| |!| |!| |!| |!| |!| |!|
Four days ago a chest tube was inserted into the second intercostal space
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
of a client who has a pneumothorax. Today the nurse notes that there is
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
no fluctuation in the water-seal chamber of the Pleuravac. Which
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
EXAM TEST BANK LATEST EXAM |!| |!| |!| |!| |!|
QUESTIONS WITH VERIFIED DETAILED |!| |!| |!| |!|
ANSWERS
The nurses calculating fluid resuscitation for young adult male who was
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
burned in a bloody accident at 1200 and is seen in the ER at 1400. The
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
HCP determines that the client has burn over 30% of his body, mainly over
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
his arms and chest. Using the Parkland formula for fluid resuscitation, the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
client is to receive 7000 mL of fluid in 24 hours. Which goal should the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
nurse establish for this clients plan of care? - correct answer✔✔By 2000,
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the client will have received 3500 mL of fluid
|!| |!| |!| |!| |!| |!| |!| |!|
When caring for a client on a vent, which finding provides the greatest
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
indication that the client has an open airway? - correct answer✔✔Bilateral
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
breath sounds can be auscultated |!| |!| |!| |!|
The nurse performs a prescribed a neurological check at the beginning of
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the shift on a client who was admitted with a subarachnoid brain attack
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
(Stroke). The client's GCS is 9. What information is most important for the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
nurse to determine? - correct answer✔✔The client's previous GCS score
|!| |!| |!| |!| |!| |!| |!| |!| |!|
An adult female with a history of type 1 diabetes has been vomiting for
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the past 48 hours and is admitted to the ICU with DKA. Which assessment
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
finding warrants immediate intervention by the nurse? - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔Excessive thirst |!|
A client admitted to the ICU after a colon resection with the formation of
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the loop colostomy. The nurse determines that the clients abdominal
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
dressing is clean and dry. Vital signs are: HR: 130, temperature: 100, BP:
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
, 88/65, and urine output of 10 mL/hr. What interventions should the nurse
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
implement? - correct answer✔✔Give a 500 mL IV fluid bolus challenge |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
A client is admitted with syncopal episodes related to a third degree heart
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
block. After the placement of a transcutaneous pacemaker, the nurse
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
observes several episodes the pacemaker failure to sense. What action
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
should the nurse take? - correct answer✔✔Increase the sensitivity
|!| |!| |!| |!| |!| |!| |!| |!|
A client is receiving CPR. After systole is confirmed in two leads and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
sending the transcutaneous pacemaker, which IV medication should be
|!| |!| |!| |!| |!| |!| |!| |!| |!|
administered? - correct answer✔✔Epinephrine (adrenaline) |!| |!| |!| |!|
A client has a chest tube connected to a closed water seal drainage
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
system with suction. What equipment should the nurse always have
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
available at the clients bedside? - correct answer✔✔Occlusive dressing
|!| |!| |!| |!| |!| |!| |!| |!|
Bretylium 1 mg/min via infusion is prescribed for a client and ventricular
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
tachycardia. The available solution is 500 mL D5W contains bretylium 1 |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
gram. The nurse should program the infusion time to deliver how many
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
mL/hr? - correct answer✔✔30 |!| |!| |!|
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
D5W at 6 mL/hr. How many mcg/min of nitroglycerin is infusing? - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔20
A client arrives in the ER complaining of pain. What description of pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
should prompt the nurse to suspect it originated in the myocardium? -
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
correct answer✔✔Produces chest heaviness with left arm pain
|!| |!| |!| |!| |!| |!| |!|
Four days ago a chest tube was inserted into the second intercostal space
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
of a client who has a pneumothorax. Today the nurse notes that there is
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
no fluctuation in the water-seal chamber of the Pleuravac. Which
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
