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HESI PN
CRITICAL
CARE
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CRITICAL CARE HESI PN
1. What assessment findings should he nurse document in the
electronic medical record for a client who is experiencing autonomic
dysreflexia after a TANSWER-4 spinal cord injury
ANSWER-Severe hypertension, diaphroresis, and flushing above the
lesion
2. 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?
ANSWER-Have the client exhale forcefully and tape 3 sides of a
sterile gauze over the insertion site
3. The nurse plans to administer a low dose prescription for
dopamine (Intropin) to a client who is in septic shock. Which
physiological parameter should the nurse use to evaluate a
therapeutic response to dopamine?
ANSWER-Urinary Output
4. The nurse assesses a male client postoperatively who has an
arterial line in the radial artery. Assessment findings include pallor,
parastesia, and slow capillary refill in the client’s right hand fingers.
What action should the nurse plan?
ANSWER-Notify the HCP
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HESI PN
CRITICAL
CARE
Downloaded by: Ariah |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
CRITICAL CARE HESI PN
1. What assessment findings should he nurse document in the
electronic medical record for a client who is experiencing autonomic
dysreflexia after a TANSWER-4 spinal cord injury
ANSWER-Severe hypertension, diaphroresis, and flushing above the
lesion
2. 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?
ANSWER-Have the client exhale forcefully and tape 3 sides of a
sterile gauze over the insertion site
3. The nurse plans to administer a low dose prescription for
dopamine (Intropin) to a client who is in septic shock. Which
physiological parameter should the nurse use to evaluate a
therapeutic response to dopamine?
ANSWER-Urinary Output
4. The nurse assesses a male client postoperatively who has an
arterial line in the radial artery. Assessment findings include pallor,
parastesia, and slow capillary refill in the client’s right hand fingers.
What action should the nurse plan?
ANSWER-Notify the HCP
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