Critical Care Hesi practice questions:
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.
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The nurse is assessing a burn victim who suffered destruction of the epidermis and some of the
dermis of the entire right arm and half the length of the right leg. How should the nurse
document the burn assessment findings?
A.) Superficial, 18% TBSA.
B.) Superficial partial-thickness, 18% TBSA.
C.) Deep-partial thickness, 27% TBSA.
D.) Full-thickness, 27% TBSA.
B.) Superficial partial-thickness, 18% TBSA
A "superficial partial-thickness" burn involves destruction of the epidermis layer and some of the
dermis layer. The total body surface area (%TBSA) is easily calculated by using the "rule of
nines" method. In this case, involvement of one arm is calculated as 9% TBSA and one-half of a
leg is 9% TBSA for a combined total of 18% TBSA. A total leg involvement is calculated as 18%
TBSA.
he critical care nurse is providing care for a client diagnosed clinically brain dead and identified
as an organ donor. Which are the nurse's priorities in providing care? (Select all that apply.)
A.) Sustaining a state of hypothermia.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
Once an identified organ donor has been declared clinically brain dead, the primary focus of
care changes from preserving life to preserving organ functioning. This is done by maintaining
normal blood pressures, fluid levels, electrolytes levels, serum glucose levels, and
normothermia. Mechanical ventilation is provided to maintain adequate oxygenation and normal
acid-base balance. If needed, pharmaceutical support is provided for the treatment of anemia,
coagulopathy, thrombocytopenia, and diabetes insipidus. Physiological changes occur to bodily
functions as the result of decreased perfusion within the brain.
, A client is admitted to the intensive care unit with hematemesis related to esophageal varices.
Which assessment finding should the nurse identify that is the result of an estimated blood loss
at 35% of total blood volume?
A.) Absent bowel sounds.
B.) Coma.
C.) Anuria.
D.) Abdominal pain.
A.) Absent bowel sounds.
Massive blood loss redirects a significant amount of blood flow to vital organs. A client who has
lost 30% to 40% of the total blood volume will exhibit absent bowel sounds, lethargy, and
increased serum potassium.
The nurse is planning care for a client admitted to the intensive care unit with acute infected
necrotizing pancreatitis. Which diagnostic procedure should the nurse prepare the client to
expect the healthcare provider to prescribe?
A.) Contrast-enhanced computed tomography (CT).
B.) Endoscopic retrograde cholangiopancreatography (ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound.
A.) Contrast-enhanced computed tomography (CT)
Contrast-enhanced computed tomography (CT) is the imaging modality of choice to evaluate
peripancreatic necrosis.
The nurse is caring for a client admitted to the surgical intensive care unit (ICU) after
undergoing gastrointestinal surgery. Which intervention should the nurse include in the plan of
care to minimize the risk for vomiting?
A.) Maintain patency of nasogastric tube to low intermittent suction.
B.) Provide a soft, bland diet with oral liquids, such as diluted juices.
C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR) solution IV at 125 mL/hour.
D.) Insert a rectal tube followed with progressive mobilization techniques.
A.) Maintain patency of nasogastric tube to low intermittent suction.
Gastrointestinal (GI) surgery often requires postoperative nasogastric tube (NGT) insertion for
low intermittent suction to prevent intestinal blockage due to absent or decreased peristalsis.
The plan of care should include maintaining patency of the NGT to low intermittent suction,
which empties the stomach and minimizes nausea and vomiting.
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.
,Brainpower
Read More
0:13
/
0:15
The nurse is assessing a burn victim who suffered destruction of the epidermis and some of the
dermis of the entire right arm and half the length of the right leg. How should the nurse
document the burn assessment findings?
A.) Superficial, 18% TBSA.
B.) Superficial partial-thickness, 18% TBSA.
C.) Deep-partial thickness, 27% TBSA.
D.) Full-thickness, 27% TBSA.
B.) Superficial partial-thickness, 18% TBSA
A "superficial partial-thickness" burn involves destruction of the epidermis layer and some of the
dermis layer. The total body surface area (%TBSA) is easily calculated by using the "rule of
nines" method. In this case, involvement of one arm is calculated as 9% TBSA and one-half of a
leg is 9% TBSA for a combined total of 18% TBSA. A total leg involvement is calculated as 18%
TBSA.
he critical care nurse is providing care for a client diagnosed clinically brain dead and identified
as an organ donor. Which are the nurse's priorities in providing care? (Select all that apply.)
A.) Sustaining a state of hypothermia.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
B.) Maintaining a normal blood pressure.
C.) Ensuring adequate oxygenation and ventilation.
D.) Treating any coagulopathy, thrombocytopenia and anemia.
E.) Monitoring arterial blood gases and serum electrolytes levels.
Once an identified organ donor has been declared clinically brain dead, the primary focus of
care changes from preserving life to preserving organ functioning. This is done by maintaining
normal blood pressures, fluid levels, electrolytes levels, serum glucose levels, and
normothermia. Mechanical ventilation is provided to maintain adequate oxygenation and normal
acid-base balance. If needed, pharmaceutical support is provided for the treatment of anemia,
coagulopathy, thrombocytopenia, and diabetes insipidus. Physiological changes occur to bodily
functions as the result of decreased perfusion within the brain.
, A client is admitted to the intensive care unit with hematemesis related to esophageal varices.
Which assessment finding should the nurse identify that is the result of an estimated blood loss
at 35% of total blood volume?
A.) Absent bowel sounds.
B.) Coma.
C.) Anuria.
D.) Abdominal pain.
A.) Absent bowel sounds.
Massive blood loss redirects a significant amount of blood flow to vital organs. A client who has
lost 30% to 40% of the total blood volume will exhibit absent bowel sounds, lethargy, and
increased serum potassium.
The nurse is planning care for a client admitted to the intensive care unit with acute infected
necrotizing pancreatitis. Which diagnostic procedure should the nurse prepare the client to
expect the healthcare provider to prescribe?
A.) Contrast-enhanced computed tomography (CT).
B.) Endoscopic retrograde cholangiopancreatography (ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound.
A.) Contrast-enhanced computed tomography (CT)
Contrast-enhanced computed tomography (CT) is the imaging modality of choice to evaluate
peripancreatic necrosis.
The nurse is caring for a client admitted to the surgical intensive care unit (ICU) after
undergoing gastrointestinal surgery. Which intervention should the nurse include in the plan of
care to minimize the risk for vomiting?
A.) Maintain patency of nasogastric tube to low intermittent suction.
B.) Provide a soft, bland diet with oral liquids, such as diluted juices.
C.) Initiate Dextrose 5% in Lactated Ringer's (D 5LR) solution IV at 125 mL/hour.
D.) Insert a rectal tube followed with progressive mobilization techniques.
A.) Maintain patency of nasogastric tube to low intermittent suction.
Gastrointestinal (GI) surgery often requires postoperative nasogastric tube (NGT) insertion for
low intermittent suction to prevent intestinal blockage due to absent or decreased peristalsis.
The plan of care should include maintaining patency of the NGT to low intermittent suction,
which empties the stomach and minimizes nausea and vomiting.
