Critical Care HESI with complete solution

The nurses calculating fluid resuscitation for young adult male who was burned in a bloody accident at 1200 and is seen in the ER at 1400. The HCP determines that the client has burn over 30% of his body, mainly over his arms and chest. Using the Parkland formula for fluid resuscitation, the client is to receive 7000 mL of fluid in 24 hours. Which goal should the nurse establish for this clients plan of care? By 2000, the client will have received 3500 mL of fluid When caring for a client on a vent, which finding provides the greatest indication that the client has an open airway? Bilateral breath sounds can be auscultated The nurse performs a prescribed a neurological check at the beginning of the shift on a client who was admitted with a subarachnoid brain attack (Stroke). The client's GCS is 9. What information is most important for the nurse to determine? The client's previous GCS score An adult female with a history of type 1 diabetes has been vomiting for the past 48 hours and is admitted to the ICU with DKA. Which assessment finding warrants immediate intervention by the nurse? Excessive thirst A client admitted to the ICU after a colon resection with the formation of the loop colostomy. The nurse determines that the clients abdominal dressing is clean and dry. Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine output of 10 mL/hr. What interventions should the nurse implement? Give a 500 mL IV fluid bolus challenge A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a transcutaneous pacemaker, the nurse observes several episodes the pacemaker failure to sense. What action should the nurse take? Increase the sensitivity A client is receiving CPR. After systole is confirmed in two leads and sending the transcutaneous pacemaker, which IV medication should be administered? Epinephrine (adrenaline) A client has a chest tube connected to a closed water seal drainage system with suction. What equipment should the nurse always have available at the clients bedside? Occlusive dressing Bretylium 1 mg/min via infusion is prescribed for a client and ventricular tachycardia. The available solution is 500 mL D5W contains bretylium 1 gram. The nurse should program the infusion time to deliver how many mL/hr? 30 The client is receiving an infusion of nitroglycerin 100 mg and 500 mL D5W at 6 mL/hr. How many mcg/min of nitroglycerin is infusing? 20 A client arrives in the ER complaining of pain. What description of pain should prompt the nurse to suspect it originated in the myocardium? Produces chest heaviness with left arm pain Four days ago a chest tube was inserted into the second intercostal space of a client who has a pneumothorax. Today the nurse notes that there is no fluctuation in the water-seal chamber of the Pleuravac. Which intervention would be most appropriate for the nurse to implement? Assess the clients breath sounds of the affected lung In developing a care plan for a client that has a chest tube due to a hemothorax, the nurse should recognize which intervention is essential? Encourage the client to breathe deeply and cough at frequent intervals A postoperative client is admitted the ICU with an inflated pressure infuser containing solution of heparin 2 units/mL attached to an intraarterial cannula. Which finding indicated that the heparin infusion has achieved its therapeutic use? Intra-arterial cannula remain patent The nurse suspects that a client with a central venous catheter in the left subclavian vein is experiencing an embolism. What signs and symptoms are most indicative of this condition? Anxiety, confusion, lightheadedness, and loss consciousness A female client has been in systole for 20 minutes. She is intubated, and epinephrine (adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in rhythm. What intervention should the nurse implement? Bring members of the family to a private area to discuss the desire to continue life saving efforts The nurse is evaluating a clients central venous pressure reading that are trending upwards. What nursing diagnosis is supported but the pathophysiological mechanism most likely causing this increase? Impaired cardiac output The high pressure alarm on a mechanical vent is alarming. What intervention should the nurse implement immediately? Auscultate bilaterally for breath sounds and confirm endotracheal suctioning A client with a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is the most important in the teaching plan? Use stool softeners regularly The ECG pattern of a client indicates that the cardiac rhythm has changed from first degree to third degree AV block. What intervention should the nurse implement? Assess the clients BP The nurse caring for a client who hemorrhaged postoperatively and is in the early stage of shock. Which cardiopulmonary symptoms are most indicative of progression into a state of shock? Increases pulse rate, lowered systolic pressure, peripheral extremity mottling A 47-year-old female client is admitted to the cardiac ICU with an acute MI, which occurred following a vigorous as a goal workout. She tells the nurse, "I just had a little indigestion; I'll be fine a little while." Which client problem has the highest priority? Decreased cardiac output Which medication should the nurse anticipate administering to a client in the ER who is experiencing a hypertensive crisis? Sodium nitroprusside (Nipride) When initiating dopamine (intropin) infusion for a hypotensive client, which intervention should the nurse include in the client's plan of care? Monitor urinary output every hour Adult female with a history of chronic adrenal insufficiency is admitted to the ICU for adrenal crisis. Which intervention should the nurse implement first? Give IV hydrocortisone a female college student suffered second and third degree burns when lighter fluid was tossed into the flames of a campfire. The burns extended along the posterior surface of each arm from the deltoid region to the hands and the interior surfaces of both legs from the groin to ankles. According to the rule of nines, what percentage of the clients body surface area is burned? 27% Nursing care from a 58 year old female client with postoperative complication include central venous pressure monitoring. What is the most important consideration a in monitoring the CVP? The zero point on the manometer must be level with the right atrium (4th intercostal space) A male client is admitted to the cardiac ICU with chest pain that began 12 hours ago. The nurse recognizes increased ventricular ectopy. Based on this assessment finding, what action is most important for the nurse to implement? Initiate the units anti arrhythmic protocol if symptomatic A client is being treated for a MI that occurred less than 6 hours ago. The cardiologist suspects 100% occlusion of the right coronary artery. The nurse is likely to find that the clients 12 lead EKG on admission exhibits which finding? Sinus bradycardia, Q waves and ST elevation in the inferior leads, QRS lengthening