2023 Critical Care Hesi Exit Exam

2023 Critical Care Hesi Exit Exam The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? - Leave the cuff inflated and suction through the tracheostomy. A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? - Assess oxygen saturation levels. The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? - "Have you ever had chest pain?" The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? - Ask the client to describe the pain. Assessment: outcome priority; must validate that client is in pain before implementation A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? - Place the client on her left side with her legs flexed. Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? - Urinary output of 1,500 mL in 24 hours. Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? - 40 mg oral furosemide (Lasix) in the morning. Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse? - "I drove to the library yesterday." Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? - The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? - A 38-year-old client with a diagnosis of systemic lupus erythematosus. Implementation: outcome desired; autoimmune disease; not infectious The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements? - "Take this doll and show me where the operation will be done." Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take? - Assist the client to a bedside commode every 2 hours. Implementation: outcome desired; keeps client active and independent The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take? - Administer the 6 units of regular insulin Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation? - Do not administer the Ceclor or naproxen; notify the healthcare provider. Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? - "I should take polyethylene glycol (MiraLax) with a large glass of water." Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds? - Deep, low-pitched rumbling sounds are heard mainly on expiration. Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication? - Monitor the serum BUN and creatinine. Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action? - Place the client supine with the foot of the bed elevated. Implementation: outcome desired; Trendelenburg or knee chest position desired to decrease pressure on umbilical cord The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse? - Sodium 128 mEq/L. Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST? - "When does your mother fall?" Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram? - Locate and note the presence of peripheral pulses. Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? - Listen to the client's breath sounds. Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action? - . Frequently inform the client of the room and bathroom location. Implementation: outcome desired; provides for safety needs and frequent orientation The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST? - A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. Real problem; vitals signs indicate significant increase in intracranial pressure; most unstable client The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective? - Baked cod, biscuit without butter, fruit roll-up. Implementation: outcome desired; low-fat, high-protein, low-residue, nonirritating, high in calories, minerals The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN? - A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days