Critical Care HESI Exam with 100% Correct Answers 2023/2024

A client recovering from a percutaneous coronary intervention (PCI) after an acute myocardial infarction is being transferred from the PACU to the Cardiac ICU. Which assessment finding should the PACU nurse inform the healthcare provider of immediately? a. onset of chest pain b. need to apply pressure dressing c. presence of occasional PVCs d. absence of any urinary output during PACU stay - Correct Answer-a. onset of chest pain This suggests the onset of another MI and reocclusion of a vessel. What is the preferred treatment of an acute MI within 12 hours of symptom onset? - Correct Answer-PCI; places a stent in the affected coronary artery How often must a PCI pressure dressing site be assessed? - Correct Answer-q30min for 4 hours qh thereafter Central Venous Pressure (CVP) - Correct Answer-the pressure of blood in the thoracic vena cava, near the right atrium of the heart; reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system; normal is 2-6 mmHg Sensitivity of a pacemaker - Correct Answer-pacing devices ability to detect what electrical activity is being generated by the patient's heart to prevent any competition between the hearts intrinsic activity Contrast Induced Nephropathy (CIN) - Correct Answer-A sudden deterioration in renal function that is caused by intravascular administration of iodinated contrast medium; typically seen with angiplasty/angiography Signs of tension pneumothorax - Correct Answer-1. affected side will have decreased or absent lung sounds 2. cyanosis 3. Tracheal deviation (late sign) 4. distended neck veins 5. tachycardia, tachypnea Pneumatic Antishock Garment - Correct Answer-An inflatable device that covers the legs and abdomen; used to splint the lower extremities or pelvis, or to control bleeding in the lower extremities or pelvis. - used for intraperitoneal hemorrhage What is the expected ABG of a pulmonary embolism? - Correct Answer-Tachypnea and tachycardia-- respiratory alkalosis A client is brought to the emergency department following a motor vehicle accident. Initial assessment reveals that the client is unconscious with a blood pressure of 165/73 mmHg, HR 50 bpm, RR 8 and irregular, temperature of 103 F. What do you suspect is happening? - Correct Answer-The findings reveal Cushing's Triad (hypertension with widening pulse pressure, bradycardia and bradypnea); this indicates increased ICP Symptoms of Right Ventricular Hypertrophy - Correct Answer-fatigue, swelling, weakness, chest pain, SOB, dizziness The nurse is caring for a client who is being weaned from mechanical ventilation. Which assessment finding indicates that the client is ready to the the endotracheal tube removed? - Correct Answer-- pulse ox: 98% with a T piece - evidence of reversal of the underlying cause of respiratory failure -PEEP 8 and FiO2 0.50 - hemodynamic stability - ability to initiate an inspiratory effort. A client with ARDS was endotracheally intubated and transferred to the ICU 12 hours ago. Upon assessment, the nurse notes bilateral rales and diminished breath sounds in the right middle lobe and bilateral lower lobes, as well as bluish nail beds. Based on the client's presentation, which actions should be taken? - Correct Answer-- Place the patient in prone position - administer prescribed Lasix Pulmonary Capillary Wedge Pressure - Correct Answer-placed in the pulmonary artery to indirectly measure left atrial pressure; 4-12 Norepinephrine (Levophed) - Correct Answer-- Uses: treatment of severe hypotension and shock -MOA: increase blood pressure and cardiac output by stimulating alpha-adrenergic receptors in the blood vessels to cause *vasoconstriction* Sodium Nitroprusside (Nitropress) - Correct Answer-Very potent vasodilator *drug of choice for hypotensive emergencies - nitrO-- vessels dilate like the O The nurse suspects that a client with ESKD has developed uremic syndrome. What did the nurse assess to support this clinical determination? - Correct Answer-pericardial friction rub; increased bleeding; hepatic encephalopathy, asterixis, peripheral neuroapthy Neurological degeneration of upper and lower motor neurons resulting in muscle atrophy, fasciculations, hyperreflexia and spasticity is called: - Correct Answer-Amyotrophic Lateral Sclerosis When should stomas be emptied? - Correct Answer-before meals or 2 hours after eating