Critical Care HESI
Two days following cardiac bypass surgery, the nurse places a client's
mediastinal chest tube to water seal. The client is using the incentive
spirometer hourly while awake. Which assessment finding warrants
intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness.
c) Water seal level 2 cm below the water seal fill line.
A client with a demand pacemaker has a telemetry tracing with a
pacing spike but no corresponding QRS complex. The client's
myocardium is eliciting a QRS after a delay of several seconds. Which
telemetry interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer.
a) Loss of capture.
,The nurse is caring for a client who underwent surgical repair of the
aorta after sustaining injuries in a fall. Which finding indicates
improved blood flow after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50.
a) Movement of lower extremities.
The nurse reports findings to the healthcare provider for a client who
was admitted to the intensive care unit today with chronic
obstructive pulmonary disease (COPD). When the nurse completes
the report using the Situation, Background, Assessment,
Recommendation (SBAR) format, which statement best supports the
nurse's reason for calling the healthcare provider?
a) Prescription for an additional respiratory treatment.
,b) Admission today with difficulty breathing.
c) History of COPD.
d) Presence of expiratory wheezes in the lower lobes.
a) Prescription for an additional respiratory treatment.
The nurse is caring for a client in the intensive care unit who is
receiving mechanical ventilation due to acute respiratory failure. The
family asks when the client will be extubated. Which information
should the nurse provide?
a) When the client breathes spontaneously in between mechanical
ventilations.
b) Once all serum electrolyte and blood chemistry levels normalize.
c) At the completion of intravenous antibiotic therapy and the
infection is resolved.
d) When the chest x-ray shows that the inflammation is resolved.
a) When the client breathes spontaneously in between mechanical
ventilations.
The decision to wean a client from mechanical ventilation
, is based on the client's spontaneous respiratory rate during trials of
interrupted ventilation.
The nurse is caring for a client with severe sepsis related to a
ruptured appendix. The client is diaphoretic and reports lower
extremity spasms. The nurse observes respirations that are uneven
and labored. Arterial blood gas (ABG) results are: pH 7.60, PaCO2 25
mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment
finding warrants immediate intervention by the nurse?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds.
b) Intercostal muscle retraction.
Intercostal muscle retraction
is a critical sign of respiratory muscle fatigue that is likely to lead to
acute respiratory failure, requiring intubation with mechanical
ventilation
Two days following cardiac bypass surgery, the nurse places a client's
mediastinal chest tube to water seal. The client is using the incentive
spirometer hourly while awake. Which assessment finding warrants
intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness.
c) Water seal level 2 cm below the water seal fill line.
A client with a demand pacemaker has a telemetry tracing with a
pacing spike but no corresponding QRS complex. The client's
myocardium is eliciting a QRS after a delay of several seconds. Which
telemetry interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer.
a) Loss of capture.
,The nurse is caring for a client who underwent surgical repair of the
aorta after sustaining injuries in a fall. Which finding indicates
improved blood flow after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50.
a) Movement of lower extremities.
The nurse reports findings to the healthcare provider for a client who
was admitted to the intensive care unit today with chronic
obstructive pulmonary disease (COPD). When the nurse completes
the report using the Situation, Background, Assessment,
Recommendation (SBAR) format, which statement best supports the
nurse's reason for calling the healthcare provider?
a) Prescription for an additional respiratory treatment.
,b) Admission today with difficulty breathing.
c) History of COPD.
d) Presence of expiratory wheezes in the lower lobes.
a) Prescription for an additional respiratory treatment.
The nurse is caring for a client in the intensive care unit who is
receiving mechanical ventilation due to acute respiratory failure. The
family asks when the client will be extubated. Which information
should the nurse provide?
a) When the client breathes spontaneously in between mechanical
ventilations.
b) Once all serum electrolyte and blood chemistry levels normalize.
c) At the completion of intravenous antibiotic therapy and the
infection is resolved.
d) When the chest x-ray shows that the inflammation is resolved.
a) When the client breathes spontaneously in between mechanical
ventilations.
The decision to wean a client from mechanical ventilation
, is based on the client's spontaneous respiratory rate during trials of
interrupted ventilation.
The nurse is caring for a client with severe sepsis related to a
ruptured appendix. The client is diaphoretic and reports lower
extremity spasms. The nurse observes respirations that are uneven
and labored. Arterial blood gas (ABG) results are: pH 7.60, PaCO2 25
mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment
finding warrants immediate intervention by the nurse?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds.
b) Intercostal muscle retraction.
Intercostal muscle retraction
is a critical sign of respiratory muscle fatigue that is likely to lead to
acute respiratory failure, requiring intubation with mechanical
ventilation
