Summary ADVANCED CLINICAL CONCEPTS HESI HINTS DOCUMENT

ADVANCED CLINICAL CONCEPTS \ dangerous and require weaning on and off. Do not
change infusion rates simultaneously.
HESI HINTS DOCUMENT
• A client is brought into the hospital suffering shock
• ARDS is an unexpected, catastrophic pulmonary
symptoms as a result of a bee sting. What is the first
complication occurring in a person with no previous
priority? Maintaining an open airway (the allergic
pulmonary problems. The mortality rate is high (50%)
reaction damages the lining of the airways causing
edema). Also, keep the client warm without
• In ARDS, a common laboratory finding is lowered PO2.
constricting clothing; keep legs elevated (not
However, these clients are not very responsive to high
concentrations of oxygen.

• Think about the physiology of the lungs by
remembering PEEP: Positive End Expiratory Pressure is
the instillation and maintenance of small amounts of
air into the alveolar sacs to prevent them from
collapsing each time the client exhales. The amount
of pressure can be set with the ventilator and is
usually around 5 to 10 cm of water.

• Suction only when secretions are present.

• Before drawing arterial blood gases from the radial
artery, perform the Allen test to assess collateral
circulation. Make the client’s hand blanch by
obliterating both the radial and ulnar pulses. Then
release the pressure over the ulnar artery only. If flow
through the ulnar artery is good, flushing will be seen
immediately. The Allen test is then positive, and the
radial artery can be used for puncture. If the Allen test
is negative, repeat on the other arm. If this test is also
negative, seek another site for arterial puncture. The
Allen test ensures collateral circulation to the hand if
thrombosis of the radial artery should follow the
puncture.

• If the client does not have O2 to his/her brain, the rest
of the injuries do not matter because death will occur.
However, they must be removed from any source of
imminent danger, such as a fire.

• PC)2 >45 or PO2 <60 on 50% O2 signifies respiratory
failure.

• A child in severe distress should be on 100% O2.

• Early signs of shock are agitation and restlessness
resulting from cerebral hypoxia.

• If cardiogenic shock exists with the presence of
pulmonary edema, i.e., from pump failure, position
client to REDUCE venous return (HIGH FOWLER’s with
legs down) in order to decrease venous return further
to the left ventricle.

• Severe shock leads to widespread cellular injury and
impairs the integrity of the capillary membranes. Fluid
and osmotic proteins seep into the extra vascular
spaces, further reducing cardiac output. A vicious
cycle of decreased perfusion to ALL cellular level
activities ensues. All organs are damaged, and if
perfusion problems exist, the damage can be
permanent.

• All vasopressors/vasodilator drugs are potent and
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, Trendelenburg because the weight of the lower • It is important for the nurse to stay current with the
organs restricts breathing). American Heart Association’s guidelines for Basic
Life Support (BLS) by being certified every two years
• Epinephrine: 1:1000, 0.2 to 0.5ml subq for mild as required.

• Epinephrine: 1:10,000, or 5ml IV for severe

• Volume expanding fluids are usually given to clients
in shock. However, if the shock is cardiogenic,
pulmonary edema may result.

• Drugs of choice for shock
- Digitalis preparations: Increase the contractility of the
heart muscle
- Vasoconstrictors (Levophed, Dopamine): Generalized
vasonconstriction to provide more available blood to
the heart to help maintain cardiac output.

• A common volume-expanding substance is plasma
and possibly whole blood.

• You are caring for a woman who was in severe
automobile accident several days ago. She has
several fractures and internal injuries. The
exploratory laparotomy was successful in controlling
the bleeding. However, today you find that this client
is bleeding from her incision, short of breath, has a
weak thready pulse, has cold and clammy skin, and
hematuria.
- What do you think is wrong with the client, and what
would you expect to do about it?
- These are typical signs and symptoms of DIC crisis.
Expect to administer IV heparin to block the
formation of thrombin (Coumadin does not do this).
However, the client described is already past the
coagulation phase and into the hemorrhagic phase.
Her management would be administration of clotting
factors along with palliative treatment of the
symptoms as they arise. (Her prognosis is poor).

• NCLEX-RN questions on CPR often deal with
prioritization of actions. Question: What actions are
required for each of the following situations?
- A 24-year old motorcycle accident vistim with a
ruptured artery if the leg is pulseless and apneic.
- A 36-year old first time pregnant woman who arrests
during labor.
- A 17-year old with no pulse or respirations who is
trapped in an overturned car, which is starting to
catch fire.
- A 40-year old businessman who arrests two days
after a cervical laminectomy.


• WHEN TO SEEK EMERGENCY MEDICAL SERVICE (EMS)
- The American Heart Association recommends that
those with known angina pectoris seek emergency
medical care if chest pain is NOT relieved by three
nitroglycerin tablets 5 minutes apart over a
150minute period.
- A person with previously unrecognized coronary
disease experiencing chest pain persisting for 2
minutes or longer should seek emergency medical
treatment.

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,• If one rescuer is performing CPR, 1 15:2 ratio of which fluctuates very little. Therefore, it is a better
compression to ventilations is performed for 4 cycles, test of renal function than is the BUN. Creatinine is
then reassess for breathing and pulse. If two rescuers generally used in conjunction with the BUN test and
are performing CPR, a 15:2 ratio is now recommended they normally are in a 1:20 ratio.
for compressions to ventilations. Perform for 15 cycles - Serum osmolality measures the concentration of
with a 100/min compression rate. When trading off, particles in a solution. It refers to the fact that the
start with compressions. same amount of solute is present, but the amount of
solvent (fluid) is decreased.
• Initiate CPR with BLS guidelines immediately, then
move on to Advanced Cardiac Life Support (ACLS)
guidelines.

• When significant arterial acidosis is noted, try to
reduce PCO2 by increasing ventilation, which will
correct arterial, venous, and tissue acidosis.
Bicarbonate may exacerbate acidosis b producing
CO2. Thus, the ACLS guidelines have recommended
bicarbonate NOT be used unless hyperkalemia and/or
preexisting acidosis is documented.

• Infants/prematures may have problems with the
following that can predispose to arrest: Beware of the
“H’s” – hypoxia, hypoglycemia, hypothermia,
increased H+ (metabolic and/or respiratory acidosis),
hypercoagulability (if polycythemia exists).

• Changes is osmolarity cause shifts in fluid. The
osmolarity of the extracellular fluid (ECF) is almost
entriely due to sodium. The osmolarity of intracellular
fluid (ICF) is related to many particles, with potassium
being the primary electrolyte. The pressures in the
ECF and the ICF are almost identical. If either ECF or
ICF change in concentration, fluid shifts from the area
of lesser concentration to the area of greater
concentration.

• Dextrose 10% is a hypertonic solution and should be
administered IV.

• Normal saline is an isotonic solution and is used for
irrigations, such as bladder irrigations or IV flush lines
with intermittent IV medication.

• Use only isotonic (neutral) solutions in irrigations,
infusions, etc., unless the specific aim is to shift fluid
into intracellular or extracellular spaces.

• Potassium imbalances are potentially life-threatening,
must be corrected immediately. A low magnesium
often accompanies a low K+, especially with the use
of diuretics.

• Fluid Volume Deficit: Dehydration
- Elevated BUN: The BUN measures the amount of urea
nitrogen in the blood. Urea is formed in the liver as the
end product of protein metabolism. The BUN is
directly related to the metabolic function of the liver
and the excretory function of the kidneys.
- Creatinine, as with BUN, is excreted entirely by the
kidneys and is therefore directly proportional to renal
excretory function. However, unlike BUN, the
creatinine level is affected very little by dehydration,
malnutrition, or hepatic function. The daily
production of creatinine depends on muscle mass,

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, Therefore, the blood can be considered “more over” the wound, after absorption of the sutures has
concentrated.” begun. Evisceration of the wound is protrusion of
- Urine osmolality and specific gravity increase. intestinal contents (in an abdominal

• Check the IV tubing container to determine the drip
factor because drip factors vary. The most common
drip factors are 10, 12, 15, and 60 drops per milliliter.
A microdrip is 60 drops per milliliter.

• Flushing a saline lock requires approximately 1 ½
times the amount of fluid that the tubing will hold in
order to efficiently flush the tubing. REMEMBER to use
sterile technique to prevent complications such as
infiltration, emboli and infection.

• A pH of less than 6.8 or more than 7.8 is NOT
COMPATIBLE WITH LIFE.

• The acronym ROME can help you remember:
Respiratory, Opposite, Metabolic, Equal.

• Review the order of blood flow to the heart:
- Unoxygenated blood flows from the superior and
inferior vena cava into the right atrium, then to the
right ventricle. It flows out of the heart through the
pulmonary artery, to the lungs for oxygenation. The
pulmonary vein delivers oxygenated blood back to
the left atrium, then to the left ventricle (largest,
strongest chamber) and out the aorta.
- Review the three structures that control the one-way
flow of blood through the heart:
1. Valves Atrioventricular valves  Tricuspid (right side) 
Mitral (left side)
Semilunar valves  Pulmonary (in
pulmonary artery)  Aortic (in aorta)
2. Cordae Tendinae
3. Papillary muscles

• Since the T waves represents repolarization of the
ventricle, this is a critical time in the heartbeat. This
action represents a resting and regrouping stage so
that the next heartbeat can occur. If defibrillation
occurs during this phase, the heart can be thrust
into a life-threatening dysrhythmia.

• Observe the client for tolerance of the current
rhythm. This information is the most important data
the nurse can collect on the client with an arrythmia.

• REMEMBER to monitor the client as well as the
machine! If the EKG monitor shows a severe
dysrhythmia, but the client is sitting up quietly
watching a TV without any sign of distress, assess to
determine if the leads are attached properly.

• Marking the operative site is required for procedures
involving right/left distinctions, multiple structures
(fingers, toes), or levels (spinal procedures). Site
marking should be done with the involvement of the
client.

• Wound dehiscence is separation of the wound edges
and is more likely to occur with vertical incisions. It
usually occurs after the early postoperative period,
when the client’s own granulation tissue is “taking
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