HESI CRITICAL CARE RN NEWEST 2024 ACTUAL EXAM
TEST BANK 2 VERSION (VERSION A AND B) 240
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A+||UPDATED MAY 2024!
Acute Respiratory Distress Syndrome (ARDS) - ANSWER: the exchange of oxygen for
carbon dioxide in the lungs is inadequate for oxygen consumption and carbon
dioxide production within the body's cells
ARDS Characterized by: - ANSWER: 1. Hypoxemia that persists even when 100%
oxygen is given. 2. Decreased pulmonary compliance. 3. Dyspnea. 4. Non-cardiac-
associated bilateral pulmonary edema. 5. Dense pulmonary infiltrates on
radiography. No abnormal lung sounds are present on auscultation because the
edema of ARDS occurs first in the interstitial spaces, not in the airways.
HESI Hint #1 - ANSWER: ARDS is an unexpected, catastrophic pulmonary
complication occurring in a person with no previous pulmonary problems. Clients are
critically ill and are managed in an ICU setting. Mortality rate is high (50%)
HESI Hint #2: Interventions to prevent complications on mechanical ventilation with
ARDS - ANSWER: Elevate HOB to at least 30 degrees. Assist with daily awakening
("sedation vacation"). Implement a comprehensive oral hygiene program. Implement
a comprehensive mobilization program.
Common causes of respiratory failure - ANSWER: 1. Exacerbation of COPD. 2.
Pneumonia. 3. TB. 4. Contusion. 5. Aspiration. 6. Inhaled toxins. 7. Emboli. 8. Drug
overdose. 9. Fluid overload. 10. DIC. 11. Shock
Nursing Assessment ARDS - ANSWER: A. dyspnea, hyperpnea, crackles (or rales). B.
Intercostal retractions. C. cyanosis, pallor D. Hypoxemia: PO <50 mmHg with FiO2
>60%. E. Diffuse pulmonary infiltrates seen on chest radiograph as "white-out"
appearance. F. Verbalized anxiety, restlessness.
Nursing Plans and Interventions ARDS - ANSWER: A. Position client for maximal lung
expansion. B. Monitor client for signs of hypoxemia and oxygen toxicity. C. Monitor
breath sounds for pneumothorax. D. Provide emotional support to decrease anxiety
and allow ventilatory to "work" the lungs. E. Monitor client hemodynamically with
essential vital signs and cardiac monitor. F. Monitor arterial blood gases (ABGs)
routinely. G. Monitor vital organ status: CNS, LOC, renal system output, and
myocardium [apical pulse, BP]). H. Monitor fluid and electrolyte balance. I. Monitor
metabolic status through routine lab work.
HESI Hint #3 - ANSWER: Suction only when secretions are present
, HESI Hint #4 - ANSWER: Before drawing a sample for ABGs from the radial artery,
perform the Allen test to assess collateral circulation. The Allen test ensures
collateral circulation to the hand if thrombosis of the radial artery should follow the
puncture.
Respiratory Failure in Children Causes - ANSWER: A. Congenital heart disease. B.
Respiratory distress syndrome. C. Infection, sepsis. D. Neuromuscular diseases. E.
Trauma and burns. F. Aspiration. G. Fluid overload and dehydration. H. Anesthesia
and narcotic overdose
Nursing Assessment: Respiratory Failure in Children - ANSWER: A. Very slow or very
rapid respiratory rate (tachypnea), dyspnea, apnea, gasping, stridor. B. Tachycardia.
C. Cyanosis, pallor, or mottled color (connotes deterioration of systemic perfusion).
D. Irritability and later, lethargy (connotes a deteriorating LOC). E. Retractions, nasal
flaring, poor air movement. F. Hypoxemia, hypercapnia, respiratory acidosis. G. Lab
data: values should be evaluated, keeping in mind the percentage of oxygen the
child is receiving.
HESI Hint #5 - ANSWER: Cardinal sings of Acute Respiratory Failure in children are
restlessness, tachypnea, tachycardia, and diaphoresis
HESI Hint #6 - ANSWER: PCO2>45 or PO2<60 on 50% O2 signifies respiratory failure.
A child in severe distress should be on 100% O2.
What PO2 value indicates respiratory failure in adults? - ANSWER: PO2 below 60
mmHg
What blood value indicates hypercapnia? - ANSWER: PCO2 above 45 mmHg
Identify the condition that exists when the PO2 is less than 50 mmHg and FiO2 is
greater than 60%. - ANSWER: Hypoxemai
List three symptoms of respiratory failure in adults - ANSWER: Dyspnea/tachypnea;
intercostal and sternal retractions; cyanosis
List four common causes of respiratory failure in children - ANSWER: Congenital
heart disease; infection or sepsis; respiratory distress syndrome; aspiration; fluid
overload and dehydration
What percentage of O2 should a child in severe respiratory distress receive? -
ANSWER: 100%
Shock - ANSWER: Widespread, serious reduction of tissue perfusion (lack of O2 and
nutrients) that, if prolonged, leads to generalized impairment of cellular functioning
Arterial pressure is the driving force of blood flow through all the organs - ANSWER:
1. It is dependent on cardiac output to perfuse the body. 2. It is dependent on
TEST BANK 2 VERSION (VERSION A AND B) 240
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED
A+||UPDATED MAY 2024!
Acute Respiratory Distress Syndrome (ARDS) - ANSWER: the exchange of oxygen for
carbon dioxide in the lungs is inadequate for oxygen consumption and carbon
dioxide production within the body's cells
ARDS Characterized by: - ANSWER: 1. Hypoxemia that persists even when 100%
oxygen is given. 2. Decreased pulmonary compliance. 3. Dyspnea. 4. Non-cardiac-
associated bilateral pulmonary edema. 5. Dense pulmonary infiltrates on
radiography. No abnormal lung sounds are present on auscultation because the
edema of ARDS occurs first in the interstitial spaces, not in the airways.
HESI Hint #1 - ANSWER: ARDS is an unexpected, catastrophic pulmonary
complication occurring in a person with no previous pulmonary problems. Clients are
critically ill and are managed in an ICU setting. Mortality rate is high (50%)
HESI Hint #2: Interventions to prevent complications on mechanical ventilation with
ARDS - ANSWER: Elevate HOB to at least 30 degrees. Assist with daily awakening
("sedation vacation"). Implement a comprehensive oral hygiene program. Implement
a comprehensive mobilization program.
Common causes of respiratory failure - ANSWER: 1. Exacerbation of COPD. 2.
Pneumonia. 3. TB. 4. Contusion. 5. Aspiration. 6. Inhaled toxins. 7. Emboli. 8. Drug
overdose. 9. Fluid overload. 10. DIC. 11. Shock
Nursing Assessment ARDS - ANSWER: A. dyspnea, hyperpnea, crackles (or rales). B.
Intercostal retractions. C. cyanosis, pallor D. Hypoxemia: PO <50 mmHg with FiO2
>60%. E. Diffuse pulmonary infiltrates seen on chest radiograph as "white-out"
appearance. F. Verbalized anxiety, restlessness.
Nursing Plans and Interventions ARDS - ANSWER: A. Position client for maximal lung
expansion. B. Monitor client for signs of hypoxemia and oxygen toxicity. C. Monitor
breath sounds for pneumothorax. D. Provide emotional support to decrease anxiety
and allow ventilatory to "work" the lungs. E. Monitor client hemodynamically with
essential vital signs and cardiac monitor. F. Monitor arterial blood gases (ABGs)
routinely. G. Monitor vital organ status: CNS, LOC, renal system output, and
myocardium [apical pulse, BP]). H. Monitor fluid and electrolyte balance. I. Monitor
metabolic status through routine lab work.
HESI Hint #3 - ANSWER: Suction only when secretions are present
, HESI Hint #4 - ANSWER: Before drawing a sample for ABGs from the radial artery,
perform the Allen test to assess collateral circulation. The Allen test ensures
collateral circulation to the hand if thrombosis of the radial artery should follow the
puncture.
Respiratory Failure in Children Causes - ANSWER: A. Congenital heart disease. B.
Respiratory distress syndrome. C. Infection, sepsis. D. Neuromuscular diseases. E.
Trauma and burns. F. Aspiration. G. Fluid overload and dehydration. H. Anesthesia
and narcotic overdose
Nursing Assessment: Respiratory Failure in Children - ANSWER: A. Very slow or very
rapid respiratory rate (tachypnea), dyspnea, apnea, gasping, stridor. B. Tachycardia.
C. Cyanosis, pallor, or mottled color (connotes deterioration of systemic perfusion).
D. Irritability and later, lethargy (connotes a deteriorating LOC). E. Retractions, nasal
flaring, poor air movement. F. Hypoxemia, hypercapnia, respiratory acidosis. G. Lab
data: values should be evaluated, keeping in mind the percentage of oxygen the
child is receiving.
HESI Hint #5 - ANSWER: Cardinal sings of Acute Respiratory Failure in children are
restlessness, tachypnea, tachycardia, and diaphoresis
HESI Hint #6 - ANSWER: PCO2>45 or PO2<60 on 50% O2 signifies respiratory failure.
A child in severe distress should be on 100% O2.
What PO2 value indicates respiratory failure in adults? - ANSWER: PO2 below 60
mmHg
What blood value indicates hypercapnia? - ANSWER: PCO2 above 45 mmHg
Identify the condition that exists when the PO2 is less than 50 mmHg and FiO2 is
greater than 60%. - ANSWER: Hypoxemai
List three symptoms of respiratory failure in adults - ANSWER: Dyspnea/tachypnea;
intercostal and sternal retractions; cyanosis
List four common causes of respiratory failure in children - ANSWER: Congenital
heart disease; infection or sepsis; respiratory distress syndrome; aspiration; fluid
overload and dehydration
What percentage of O2 should a child in severe respiratory distress receive? -
ANSWER: 100%
Shock - ANSWER: Widespread, serious reduction of tissue perfusion (lack of O2 and
nutrients) that, if prolonged, leads to generalized impairment of cellular functioning
Arterial pressure is the driving force of blood flow through all the organs - ANSWER:
1. It is dependent on cardiac output to perfuse the body. 2. It is dependent on
