2023 HESI RN CRITICAL CARE /CRITICAL CARE RN HESI EXIT
ACTUAL EXAM 2 !!!! CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
Acute Respiratory Distress Syndrome (ARDS) - (answers)the exchange of oxygen for carbon
dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production
within the body's cells
ARDS Characterized by: - (answers)1. Hypoxemia that persists even when 100% oxygen is
given. 2. Decreased pulmonary compliance. 3. Dyspnea. 4. Non-cardiac-associated bilateral
pulmonary edema. 5. Dense pulmonary infiltrates on radiography. No abnormal lung sounds
are present on auscultation because the edema of ARDS occurs first in the interstitial spaces,
not in the airways.
HESI Hint #1 - (answers)ARDS is an unexpected, catastrophic pulmonary complication
occurring in a person with no previous pulmonary problems. Clients are critically ill and are
managed in an ICU setting. Mortality rate is high (50%)
HESI Hint #2: Interventions to prevent complications on mechanical ventilation with ARDS -
(answers)Elevate HOB to at least 30 degrees. Assist with daily awakening ("sedation
vacation"). Implement a comprehensive oral hygiene program. Implement a comprehensive
mobilization program.
Common causes of respiratory failure - (answers)1. Exacerbation of COPD. 2. Pneumonia. 3.
TB. 4. Contusion. 5. Aspiration. 6. Inhaled toxins. 7. Emboli. 8. Drug overdose. 9. Fluid
overload. 10. DIC. 11. Shock
Nursing Assessment ARDS - (answers)A. dyspnea, hyperpnea, crackles (or rales). B.
Intercostal retractions. C. cyanosis, pallor D. Hypoxemia: PO <50 mmHg with FiO2 >60%. E.
Diffuse pulmonary infiltrates seen on chest radiograph as "white-out" appearance. F.
Verbalized anxiety, restlessness.
Nursing Plans and Interventions ARDS - (answers)A. Position client for maximal lung
expansion. B. Monitor client for signs of hypoxemia and oxygen toxicity. C. Monitor breath
, sounds for pneumothorax. D. Provide emotional support to decrease anxiety and allow
ventilatory to "work" the lungs. E. Monitor client hemodynamically with essential vital signs
and cardiac monitor. F. Monitor arterial blood gases (ABGs) routinely. G. Monitor vital organ
status: CNS, LOC, renal system output, and myocardium [apical pulse, BP]). H. Monitor fluid
and electrolyte balance. I. Monitor metabolic status through routine lab work.
HESI Hint #3 - (answers)Suction only when secretions are present
HESI Hint #4 - (answers)Before drawing a sample for ABGs from the radial artery, perform
the Allen test to assess collateral circulation. The Allen test ensures collateral circulation to
the hand if thrombosis of the radial artery should follow the puncture.
Respiratory Failure in Children Causes - (answers)A. Congenital heart disease. B. Respiratory
distress syndrome. C. Infection, sepsis. D. Neuromuscular diseases. E. Trauma and burns. F.
Aspiration. G. Fluid overload and dehydration. H. Anesthesia and narcotic overdose
Nursing Assessment: Respiratory Failure in Children - (answers)A. Very slow or very rapid
respiratory rate (tachypnea), dyspnea, apnea, gasping, stridor. B. Tachycardia. C. Cyanosis,
pallor, or mottled color (connotes deterioration of systemic perfusion). D. Irritability and
later, lethargy (connotes a deteriorating LOC). E. Retractions, nasal flaring, poor air
movement. F. Hypoxemia, hypercapnia, respiratory acidosis. G. Lab data: values should be
evaluated, keeping in mind the percentage of oxygen the child is receiving.
HESI Hint #5 - (answers)Cardinal sings of Acute Respiratory Failure in children are
restlessness, tachypnea, tachycardia, and diaphoresis
HESI Hint #6 - (answers)PCO2>45 or PO2<60 on 50% O2 signifies respiratory failure. A child
in severe distress should be on 100% O2.
What PO2 value indicates respiratory failure in adults? - (answers)PO2 below 60 mmHg
What blood value indicates hypercapnia? - (answers)PCO2 above 45 mmHg
ACTUAL EXAM 2 !!!! CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+
Acute Respiratory Distress Syndrome (ARDS) - (answers)the exchange of oxygen for carbon
dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production
within the body's cells
ARDS Characterized by: - (answers)1. Hypoxemia that persists even when 100% oxygen is
given. 2. Decreased pulmonary compliance. 3. Dyspnea. 4. Non-cardiac-associated bilateral
pulmonary edema. 5. Dense pulmonary infiltrates on radiography. No abnormal lung sounds
are present on auscultation because the edema of ARDS occurs first in the interstitial spaces,
not in the airways.
HESI Hint #1 - (answers)ARDS is an unexpected, catastrophic pulmonary complication
occurring in a person with no previous pulmonary problems. Clients are critically ill and are
managed in an ICU setting. Mortality rate is high (50%)
HESI Hint #2: Interventions to prevent complications on mechanical ventilation with ARDS -
(answers)Elevate HOB to at least 30 degrees. Assist with daily awakening ("sedation
vacation"). Implement a comprehensive oral hygiene program. Implement a comprehensive
mobilization program.
Common causes of respiratory failure - (answers)1. Exacerbation of COPD. 2. Pneumonia. 3.
TB. 4. Contusion. 5. Aspiration. 6. Inhaled toxins. 7. Emboli. 8. Drug overdose. 9. Fluid
overload. 10. DIC. 11. Shock
Nursing Assessment ARDS - (answers)A. dyspnea, hyperpnea, crackles (or rales). B.
Intercostal retractions. C. cyanosis, pallor D. Hypoxemia: PO <50 mmHg with FiO2 >60%. E.
Diffuse pulmonary infiltrates seen on chest radiograph as "white-out" appearance. F.
Verbalized anxiety, restlessness.
Nursing Plans and Interventions ARDS - (answers)A. Position client for maximal lung
expansion. B. Monitor client for signs of hypoxemia and oxygen toxicity. C. Monitor breath
, sounds for pneumothorax. D. Provide emotional support to decrease anxiety and allow
ventilatory to "work" the lungs. E. Monitor client hemodynamically with essential vital signs
and cardiac monitor. F. Monitor arterial blood gases (ABGs) routinely. G. Monitor vital organ
status: CNS, LOC, renal system output, and myocardium [apical pulse, BP]). H. Monitor fluid
and electrolyte balance. I. Monitor metabolic status through routine lab work.
HESI Hint #3 - (answers)Suction only when secretions are present
HESI Hint #4 - (answers)Before drawing a sample for ABGs from the radial artery, perform
the Allen test to assess collateral circulation. The Allen test ensures collateral circulation to
the hand if thrombosis of the radial artery should follow the puncture.
Respiratory Failure in Children Causes - (answers)A. Congenital heart disease. B. Respiratory
distress syndrome. C. Infection, sepsis. D. Neuromuscular diseases. E. Trauma and burns. F.
Aspiration. G. Fluid overload and dehydration. H. Anesthesia and narcotic overdose
Nursing Assessment: Respiratory Failure in Children - (answers)A. Very slow or very rapid
respiratory rate (tachypnea), dyspnea, apnea, gasping, stridor. B. Tachycardia. C. Cyanosis,
pallor, or mottled color (connotes deterioration of systemic perfusion). D. Irritability and
later, lethargy (connotes a deteriorating LOC). E. Retractions, nasal flaring, poor air
movement. F. Hypoxemia, hypercapnia, respiratory acidosis. G. Lab data: values should be
evaluated, keeping in mind the percentage of oxygen the child is receiving.
HESI Hint #5 - (answers)Cardinal sings of Acute Respiratory Failure in children are
restlessness, tachypnea, tachycardia, and diaphoresis
HESI Hint #6 - (answers)PCO2>45 or PO2<60 on 50% O2 signifies respiratory failure. A child
in severe distress should be on 100% O2.
What PO2 value indicates respiratory failure in adults? - (answers)PO2 below 60 mmHg
What blood value indicates hypercapnia? - (answers)PCO2 above 45 mmHg
