HESI Critical Care Exam Review
Questions and Answers26
The nurse in the hospital emergency department is preparing to administer fomepizole to a
client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this
medication by which route?
Oral route
Intramuscular route
Intravenous (IV) route
Through a nasogastric tube - ANSWERS-Intravenous (IV) route
The nurse is reviewing the medical record of a client transferred to the medical unit from the
critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP)
therapy while in the critical care unit. The nurse suspects that the client received this therapy
for which condition?
Heart failure
Pulmonary edema
Cardiogenic shock
,Aortic insufficiency - ANSWERS-Cardiogenic shock
Rationale:
IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if
instituted early in the course of treatment. Use of IABP therapy is contraindicated in clients with
aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the
treatment of congestive heart failure or pulmonary edema.
The emergency department nurse is monitoring a client who received treatment for a severe
asthma attack. The nurse determines that the client's respiratory status has worsened if which is
noted on assessment?
Diminished breath sounds
Wheezing during inhalation
Wheezing during exhalation
Wheezing throughout the lung fields - ANSWERS-Diminished breath sounds
Rationale:
Diminished breath sounds may be an indication of severe obstruction and possibly respiratory
failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack.
For wheezing to occur, the client must be able to move sufficient air to produce breath sounds.
Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may
wheeze during both inspiration and expiration.
The nurse caring for a client with a chest tube turns the client to the side and the chest tube
accidentally disconnects from the water seal chamber. Which initial action should the nurse
take?
, Call the health care provider (HCP).
Place the tube in a bottle of sterile water.
Replace the chest tube system immediately.
Place a sterile dressing over the disconnection site. - ANSWERS-Place the tube in a bottle of
sterile water.
Rationale:
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile
water held below the level of the chest. The HCP may need to be notified, but this is not the
initial action. The system is replaced if it breaks or cracks or if the collection chamber is full.
Placing a sterile dressing over the disconnection site will not prevent complications resulting
from the disconnection.
The nurse has completed 5 cycles of compressions after beginning cardiopulmonary
resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest.
What should the nurse plan to do next?
Prepare epinephrine.
Charge the defibrillator.
Check the client's heart rhythm.
Pause CPR for 20 seconds and reassess. - ANSWERS-Charge the defibrillator.
Questions and Answers26
The nurse in the hospital emergency department is preparing to administer fomepizole to a
client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this
medication by which route?
Oral route
Intramuscular route
Intravenous (IV) route
Through a nasogastric tube - ANSWERS-Intravenous (IV) route
The nurse is reviewing the medical record of a client transferred to the medical unit from the
critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP)
therapy while in the critical care unit. The nurse suspects that the client received this therapy
for which condition?
Heart failure
Pulmonary edema
Cardiogenic shock
,Aortic insufficiency - ANSWERS-Cardiogenic shock
Rationale:
IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if
instituted early in the course of treatment. Use of IABP therapy is contraindicated in clients with
aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the
treatment of congestive heart failure or pulmonary edema.
The emergency department nurse is monitoring a client who received treatment for a severe
asthma attack. The nurse determines that the client's respiratory status has worsened if which is
noted on assessment?
Diminished breath sounds
Wheezing during inhalation
Wheezing during exhalation
Wheezing throughout the lung fields - ANSWERS-Diminished breath sounds
Rationale:
Diminished breath sounds may be an indication of severe obstruction and possibly respiratory
failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack.
For wheezing to occur, the client must be able to move sufficient air to produce breath sounds.
Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may
wheeze during both inspiration and expiration.
The nurse caring for a client with a chest tube turns the client to the side and the chest tube
accidentally disconnects from the water seal chamber. Which initial action should the nurse
take?
, Call the health care provider (HCP).
Place the tube in a bottle of sterile water.
Replace the chest tube system immediately.
Place a sterile dressing over the disconnection site. - ANSWERS-Place the tube in a bottle of
sterile water.
Rationale:
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile
water held below the level of the chest. The HCP may need to be notified, but this is not the
initial action. The system is replaced if it breaks or cracks or if the collection chamber is full.
Placing a sterile dressing over the disconnection site will not prevent complications resulting
from the disconnection.
The nurse has completed 5 cycles of compressions after beginning cardiopulmonary
resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest.
What should the nurse plan to do next?
Prepare epinephrine.
Charge the defibrillator.
Check the client's heart rhythm.
Pause CPR for 20 seconds and reassess. - ANSWERS-Charge the defibrillator.
