Critical Care HESI
1 . What assessment findings should the nurse document in the electronic medical record for
a client who is experiencing
autonomic dysreflexia after a T-4 spinal cord injury?
Ans:
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?
Ans:
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?
Ans:
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?
Ans:
Notify the HCP
5 . A male client is admitted to the cardiac intensive unit with chest pain that began twelve
hours ago. The nurse recognizes
increased ventricular ectopy? Based on this assessment finding, what actions is most
important for the nurse to
implement?
Ans:
Initiate the unit's antiarrhythmic protocol if symptomatic.
6 . The nurse is assessing a client who was admitted 24 hours ago to the critical care unit
following a motorcycle collision.
Which client finding requires intervention by the nurse to reduce the risk for complication
related to increased
intracranial pressure?
Ans:
, Change of PaCo2 to 55 mm Hg following ventilator setting adjustments
7 . A client is receiving cardiopulmonary resuscitation. After asystole is confirmed in two
leads and sending for the
transcutaneous pacemaker, which intravenous medication should be administered?
Ans:
Epinephrine
8 . The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted to the
hospital with a subarachnoid brain attack (stroke). The client's Glasgow coma scale is 9.
What information is most
important for the nurse to determine?
Ans:
The client's previous GCS score
9 . The healthcare provider prescribes a STAT computerized tomography without contrast for
a client who is exhibiting
signs of an acute change in the level of consciousness. The nurse is caring for two additional
intensive care clients and has
an unlicensed assistive personnel assigned to assist with the delivery of care. What action
should the nurse take?
Ans:
Administered the schedule medications prior to transporting the client to CT scan.
10 . The healthcare provider prescribes and IV fluid bolus for a client who was admitted two
hours ago to the ICU because
of adrenal crisis. The client is confused and uncooperative. The nurse has attempted two
times to obtain IV access without
success. Which intervention should the nurse implement first?
Ans:
Ask another nurse to attempt insertion of IV
11 . Arterial blood gas results indicate that a client with respiratory failure who is being
mechanically ventilated has
respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm
H2O and oxygen
concentration of 30%. Which action should help correct the client's acidosis?
- Provide manual resuscitation
- Increase oxygen concentration
- Decrease the pressure support
- Increase the ventilator rate
1 . What assessment findings should the nurse document in the electronic medical record for
a client who is experiencing
autonomic dysreflexia after a T-4 spinal cord injury?
Ans:
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?
Ans:
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?
Ans:
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?
Ans:
Notify the HCP
5 . A male client is admitted to the cardiac intensive unit with chest pain that began twelve
hours ago. The nurse recognizes
increased ventricular ectopy? Based on this assessment finding, what actions is most
important for the nurse to
implement?
Ans:
Initiate the unit's antiarrhythmic protocol if symptomatic.
6 . The nurse is assessing a client who was admitted 24 hours ago to the critical care unit
following a motorcycle collision.
Which client finding requires intervention by the nurse to reduce the risk for complication
related to increased
intracranial pressure?
Ans:
, Change of PaCo2 to 55 mm Hg following ventilator setting adjustments
7 . A client is receiving cardiopulmonary resuscitation. After asystole is confirmed in two
leads and sending for the
transcutaneous pacemaker, which intravenous medication should be administered?
Ans:
Epinephrine
8 . The nurse performs a prescribed neurological check at the beginning of the shift on a
client who was admitted to the
hospital with a subarachnoid brain attack (stroke). The client's Glasgow coma scale is 9.
What information is most
important for the nurse to determine?
Ans:
The client's previous GCS score
9 . The healthcare provider prescribes a STAT computerized tomography without contrast for
a client who is exhibiting
signs of an acute change in the level of consciousness. The nurse is caring for two additional
intensive care clients and has
an unlicensed assistive personnel assigned to assist with the delivery of care. What action
should the nurse take?
Ans:
Administered the schedule medications prior to transporting the client to CT scan.
10 . The healthcare provider prescribes and IV fluid bolus for a client who was admitted two
hours ago to the ICU because
of adrenal crisis. The client is confused and uncooperative. The nurse has attempted two
times to obtain IV access without
success. Which intervention should the nurse implement first?
Ans:
Ask another nurse to attempt insertion of IV
11 . Arterial blood gas results indicate that a client with respiratory failure who is being
mechanically ventilated has
respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm
H2O and oxygen
concentration of 30%. Which action should help correct the client's acidosis?
- Provide manual resuscitation
- Increase oxygen concentration
- Decrease the pressure support
- Increase the ventilator rate
