Critical Care HESI 2023 with verified questions and answers

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 Six hours after surgery for a ruptured appendix, the client has a WBC of 17,000 mm3, abdominal tenderness, and abdominal rigidity. The nurse should recognize the client is exhibiting symptoms of which condition? Peritonitis The nurse assess the telemetry monitor of a client who is 24 hours postoperative for a permanent pacemaker insertion. The nurse notes that the pacemaker spike is present prior to each QRS complex in lead 2. What intervention should the nurse implement? Document that the client is experiencing a paced rhythm The nurse assess a female client following surgery for a gun shot wound to the abdomen and determined that the dressing is saturated with blood and petechiae on the extremities. Her current BP is 80/40, HR 130 bpm. Which laboratory finding confirms the presence of disseminating intravascular regulation? Postive D Dimer A clients ventilator has indicated progressively higher levels of pressure within the past 3 minutes. The pulse oximeter shows diminishing oxygenation saturation from 97% to 92% despite the maintenance of all settings: FiO2 50%, IMV 18, and PEEP 5 cm. The ET tube is correctly placed and taped. What action should the nurse take? Suction the ET Tube A client arrives in the ER via ambulance with injuries that resulted from being hit by a bus. Vital signs on admission are: BP 126/78, HR 100 bpm, RR 28, temperature 99F. Bloody drainage is noted at the clients left ear canal. What should the nurse do to assess for possible basilar skull fracture and cerebral spinal fluid leak? Gently dab blood from the ear with a sterile gauze and observe for Halo When should the nurse conduct an Allen's test? Just before ABG are drawn peripherally The nurse administers a thrombolytic agent to a client who is experiencing angina and ECG changes are indicative of an acute MI. Which assessment best indicates that the medication has has the desired effect? Client reports cessation of angina A male client with an implanted cardioverter/defibrillator (ICD) reports to the home health nurse that he feels dizzy when the device discharges. What intervention is most important for the nurse to implement? Advise the client to lie down immediately when dizziness occurs A client diagnosed with acute pancreatitis is admitted to the ICU with a temperature of 102F, pulse rate 138, RR 32, and BP 80/40. Which finding should the nurse report to the healthcare provider immediately? Hemorrhagic discoloration of the umbilicus The nurse caring for a client on a ventilator notes that the client has asymmetrical chest excursion. What intervention should he nurse implement? Determine the clients endotracheal tube placement The healthcare provider prescribes an IV solution of isoproterenol (Isopernel) 1 mg in 250 mL of D5W at 300 mcg/hr. The nurse should program the infusion top to deliver how many mL/hr? 75 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 place a vaseline gauze over the insertion site A client who sustained severe liver lacerations from a motorcycle collision is transported to the ICU following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from the surgical sit. What action should the nurse take? Prepare the client to return to the OR A male rescued from a house fire is admitted with ARDS related to severe smoke inhalation. He is orally intubated and mechanically ventilated with 100% FiO2, but breath sounds are faint and the peak inspiratory pressures are greater than 60 cm H2O. What action should the nurse implement first? Provide manual ventilation A female client who received second ad third degree burns over 40% of her body in a house fire is admitted to the inpatient burn unit. What fluid should the nurse expect to administer to the client during the acute phase of her burn recovery? Lactated Ringers A client with a resolving hemothorax has had a chest tube to gravity drainage side removal of section the previous day. What assessment finding requires nursing action? Continuous air bubbles in the water seal chamber A client with bleeding esophageal varies receives vasopressin (Pitressin) IV. What should the nurse carefully monitor for during IV infusion of this medication? Chest pain and dysrhythmias A client is receiving IV heparin and oral Warfarin (Coumadin) after a pulmonary embolism. The nurse determines the clients activated partial prothromboplastin time (aPTT) value is two times the control value; a prothrombin time (PT) level is the same as the control, and the INR is 1. Which protocol prescription should the nurse implant? increase the Coumadin dose A female client who is 4 hours post-laportomy, has rapidly increasing abdominal distention, with elevated pulse and RR. Her skin is cool and pale, but there is no change in her BP. What intervention should the nurse implement immediately? Notify the HCP of the clients status The nurse is assisting the HCP during insertion of a pulmonary artery (PA) catheter into a client with heart failure. While the PA catheter is advances, the nurse observes the monitor. Which sequence of pressure reading on the hemodynamic monitor indicate the PA is advancing? Right Atrium Right Ventricle Pulmonary Artery Pulmonary Artery Wedge After an endotracheal tube is placed for a client who requires mechanical ventilation, which intervention should the nurse implant first? Auscultate breath sounds bilaterally in lung fields On admission to the ICU for sepsis due to ruptured appendix, a female client's temperature is 39.8C and her BP is 68/42. Other hemodynamic findings include: cardiac output of 10.71 L/min, systemic vascular resistance of 470, and WBC count of 28,000/ Which classification of medications is likely to be stabilized for this client? Vasoconstrictor As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids. What is the primary purpose of withholding fluids from this client? Decreasing the formation and secretion of pancreatic enzyme A client who has a craniotomy yesterday develops an oral temperature of 103F. The nurse gives the client a tepid sponge bath. With instituting measure to reduce the clients fever, what additional action should be taken to prevent an increase in intracranial pressure? Limit exposure to shivering A client has been treated for uncontrolled A. Fib with cardioversion. Following the cardioversion, what assessment finding indicated to the nurse the desired outcome of the procedure was achieved? Normal sinus rhythms with rate for 84 What intervention is most important for the nurse ti implement when dealing with family members of a critically ill client? Offer the family current information about the clients condition