Critical Care HESI Exam - Questions and Answers

Critical Care HESI Exam - Questions and Answers Which interventions are appropriate for a right handed client recovering from a right sided CVA? a. bed low and locked b. call bell placed on right side c. notepad and pen available d. pillows to support the right side e. reposition q2h while supporting the right side with a right sided CVA, the left side is affected. C, D and E are optimal interventions for a left sided stroke. LeVeen Shunt a system used to treat ascites. Fluid is shunted from the abdominal cavity into the superior vena cava into circulation Cross contamination vs. auto-contamination - cross contamination involves transfer of microbes from person to person while auto contamination is transfer of microbes from one site of the body to another - to prevent cross-- wash hands, isolation - to prevent auto-- apply new sterile gloves per dressing, dress each wound separately, debride Normal level aPTT vs. on heparin - 30-40 seconds - on heparin: 1.5-2.5 x that (45-100 sec) Normal PT vs. on medications - normal: 11 - 12.5 sec - on anticoagulants: 1.5 - 2x that (16.5 - 25 sec) Normal INR vs. on anticoagulants - normal: 0.8-1.2 - on warfarin: 2-3 Ankylosing Spondylitis (AS) inflammatory response that causes degenerative changes in the spinal vertebrae; sacroiliac joints; connective tissues such as tendons and ligaments in the hips, shoulders, knees, feet, and ribs; and tissues of the lungs, eyes, and heart valves SIRS Criteria temp 38C or 36, 4 WBC or 12, HR90, RR20 Adrenal Insufficiency also known as Addison's disease; hyposecretion of adrenal hormones such as ADH, aldosterone and androgens - weight loss - hypoglycemia - hyponatremia - hyperkalemia - hyperpigmentation Cholinergic Crisis (DUMBBELLS) overdose of Pyridostigmine TOO MUCH ACH (skeletal muscle neurotransmitter) Diaphoresis Urination Miosis Bradycardia Bronchoconstriction Emesis Lacrimation Salivation Rx: atropine (increases HR); may need vent. Nursing: rest periods, avoid extreme temps & people with resp infections Anticholinergic Crisis overdose of atropine - blind as a bat, hot as a hare, red as a beet, dry as a bone, full as a flask, mad as a hatter - TX: DC atropine; manage symptoms; physostigmine The 15/15 Rule used to treat hypoglycemic episodes -15 grams of fast-acting carbohydrates (simple sugar) -Repeat in 15 minutes if blood glucose is 60 mg/DL or still symptomatic -Follow with snack that contains complex carbohydrates