HESI RN EVOLVE Critical Care Practice Quiz/ Latest 2022:2023/ Guaranteed A+ Guide

The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two inches above and left of the victim's xiphoid process. Which vital organ(s) are at an increased risk of being in the direct path of injury? Correct Answer: Heart Lungs Diaphragm What way do females stab? Correct Answer: Downwards What way do males stab? Correct Answer: Upwards A client reports to the nurse feeling achy and weak, being tired and coughing all the time, frequent headaches and experiencing night sweats. The client's assessment is significant for crackles scattered throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse prepare to do first? Correct Answer: Blood culture Define: Infective endocarditis Correct Answer: Infection of the endocardial surface of the heart, usually the heart valves What indicates ineffective endocarditis? Correct Answer: Edema & S1/S3 sounds According to the paramedic's report, the victim of a motor vehicle collision was sitting in the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic light when the vehicle was hit on the left side by another vehicle traveling at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L) side of thorax and body. The significant assessment findings include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is present in the (L) flank area and progresses towards the abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula. Correct Answer: Fractured liver & ruptured spleen The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse interpret this blood gas? Correct Answer: Respiratory alkalosis Define: Respiratory alkalosis Correct Answer: HCO3 & pH is increased while the CO2 is decreased What is the effect if blood sugar continues to rise? Correct Answer: Change in level of consciousness What precaution should a patient be on with a high sodium? Correct Answer: Seizure precautions Why do people with diabetes have an increased urinary output? Correct Answer: Low ADH What is the effect of a low ADH? Correct Answer: Dehydration & increased serum Sodium A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription should the nurse implement first? Correct Answer: Obtain serum sodium every 4 hours The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process? Correct Answer: Encourage the family to give the patient permission to die The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the nurse? Correct Answer: Intercostal muscle contraction Define: Intercostal muscle contraction Correct Answer: Critical sign of respiratory muscle fatigue which is likely to lead to acute respiratory failure Define: Cistacurium Correct Answer: Paralytic during surgery A client who experienced an intracranial hemorrhage is receiving cistracurium to induce a pharmacological state of paralysis. Which intervention should the nurse implement during the therapeutic paralysis? Correct Answer: Administer a sedating medication A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted. Which finding should the nurse observe for during the immediate hours after insertion? Correct Answer: Beck's Triad What are pacemakers & defibrillators able to cause? Correct Answer: Bleeding into the pericardial sac which causes a high risk for cardiac tamponade Define: Cardiac tamponade Correct Answer: Blood or fluid fills the space between the heart & its sac Define: Beck's triad Correct Answer: Signs of pericardial tamponade with low arterial BP, distended neck veins, & muffled heart sounds What is a normal arterial BP? Correct Answer: 70-100mmHg A client with a demand pacemaker has a telemetry tracing with a pacing spike but no corresponding QRS complex. The client's myocardium is illiciting a QRS after a delay of several seconds. Which telemetry interpretation should the nurse conclude? Correct Answer: Loss of capture What is indicated if there is a pacemaker spike that does not produce a QRS complex? Correct Answer: Loss of capture A client who arrived in the emergency department is experiencing status epilepticus. Which medication should the nurse administer immediately? Correct Answer: Lorazepam IV What should you give a client experiencing epilepsy? Correct Answer: CNS depressant Define: Thyroidectomy Correct Answer: Surgical removal of the thyroid gland A client who returns to the postoperative unit after a total thyroidectomy suddenly becomes short of breath and develops stridor. What action should the nurse implement first? Correct Answer: Call the rapid response team for emergency assistance What complication can happen after a thyroidectomy? Correct Answer: Bleeding into the soft tissue around the incision site causing inspiratory stridor & laryngospasm Define: Stridor Correct Answer: Stra