Critical Care (HESI)

+Critical Care HESI+ 1. What assessment findings should he nurse document in the electronic medical record for a client who is experiencing autonomic dysreflexia after a T-4 spinal cord injury -Severe hypertension, diaphroresis, and flushing above the lesion 2. As the nurse is turning a client with a chest tube, the chest tube becomes dislodged from the pleural space. What action should the nurse take first? -Have the client exhale forcefully and tape 3 sides of a sterile gauze over the insertion site 3. The nurse plans to administer a low dose prescription for dopamine (Intropin) to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine? -Urinary Output 4. The nurse assesses a male client postoperatively who has an arterial line in the radial artery. Assessment findings include pallor, parastesia, and slow capillary refill in the client’s right hand fingers. What action should the nurse plan? -Notify the HCP 5. A male client is admitted to the cardiac intensive unit with chest pain that began twelve hours ago. The nurse recognizes increased ventricular ectopy? Based on this assessment finding, what actions is most important for the nurse to implement? -Initiate the unit’s antiarrhythmic protocol if symptomatic. 6. The nurse is assessing a client who was admitted 24 hours ago to the critical care unit following a motorcycle collision. Which client finding requires intervention by the nurse to reduce the risk for complication related to increased intracranial pressure? -Change of PaCo2 to 55 mm Hg following ventilator setting adjustments 7. A client is receiving cardiopulmonary resuscitation. After asystole is confirmed in two leads and sending for the transcutaneous pacemaker, which intravenous medication should be administered? -Epinephrine 8. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow coma scale is 9. What information is most important for the nurse to determine? -The client’s previous GCS score 9. The healthcare provider prescribes a STAT computerized tomography without contrast for a client who is exhibiting signs of an acute change in the level of consciousness. The nurse is caring for two additional intensive care clients and has an unlicensed assistive personnel assigned to assist with the delivery of care. What action should the nurse take? -Administered the schedule medications prior to transporting the client to CT scan. 10. The healthcare provider prescribes and IV fluid bolus for a client who was admitted two hours ago to the ICU because of adrenal crisis. The client is confused and uncooperative. The nurse has attempted two times to obtain IV access without success. Which intervention should the nurse implement first? -Ask another nurse to attempt insertion of IV 11. Arterial blood gas results indicate that a client with respiratory failure who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm H2O and oxygen concentration of 30%. Which action should help correct the client’s acidosis? -Provide manual resuscitation (I’M 90 % SURE THIS IS THE ANSWER) Im having a brain fart -Increase oxygen concentration -Decrease the pressure support -Increase the ventilator rate 12. An adult present to the emergency department with complaints of epigastric discomfort. The client reports shortness of breath and fatigue for the past two days. Which action should the nurse implement first? -Place leads for an electrocardiogram -Administer an antacid per protocol -Obtain a blood specimen for cardiac enzymes -Ask of taking non-steroidal anti-inflammatory drugs (THIS IS NOT THE ANSWER)