LATEST HESI: Critical Care TEST SOLUTIONS 100 % CORRECT ANSWERS

The nurse in the hospital emergency department is preparing to administer fomepizole to a client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this medication by which route? Oral route Intramuscular route Intravenous (IV) route Through a nasogastric tube - ANSWER Intravenous (IV) route The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? Heart failure Pulmonary edema Cardiogenic shock Aortic insufficiency - ANSWER Cardiogenic shock Rationale: IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of IABP therapy is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema. The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment? Diminished breath sounds Wheezing during inhalation Wheezing during exhalation Wheezing throughout the lung fields - ANSWER Diminished breath sounds Rationale: Diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? Call the health care provider (HCP). Place the tube in a bottle of sterile water. Replace the chest tube system immediately. Place a sterile dressing over the disconnection site. - ANSWER Place the tube in a bottle of sterile water. Rationale: If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? Prepare epinephrine. Charge the defibrillator. Check the client's heart rhythm. Pause CPR for 20 seconds and reassess. - ANSWER Charge the defibrillator. Rationale: For witnessed adult cardiac arrest when a defibrillator is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom a defibrillator is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use. After completing 5 cycles of compressions and ventilations, the nurse should reassess the client by checking the heart rhythm. Defibrillation may be warranted depending on the assessed rhythm. Epinephrine may be prepared depending on the rhythm, but this would be prescribed by a health care provider (HCP). Chest compressions should not be interrupted for more than 10 seconds. A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? Remove the dressing. Reinforce the dressing. Call the health care provider (HCP). Measure oxygen saturation by oximetry. - ANSWER Remove the dressing. Rationale: Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the HCP, but these would not be the first actions in this situation