Critical Care Exit Hesi Exam Questions And Answers Verified 100% Correct

Critical Care Exit Hesi Exam Questions And Answers Verified 100% Correct Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant smile, loss of tonal hearing Right hemisphere lesion Most important indicator of increased ICP Change in LOC Spinal shock Complete loss of all reflexes If the U wave is most prominent what condition hypokalemia Burns First degree- epidermis {superficial} Second degree- epidermis and dermis {deep partial} Third degree- epidermis, dermis, and subQ {full thickness} Pic of patient and description of burns, need to decide what % burned [Rule of 9s- head and neck=9%, UE=9% each, LE=18% each, front trunk=18%, back trunk=18%] 5 Ps of neurovascular status (important with fractures) Pain, pallor, pulse, paresthesia, paralysis S/S of shock Increased pulse and decreased BP S/S of IICP Decreased pulse and increased BP with changes in LOC Suspected Post op bleeding if assess Frequent swallowing, vomiting blood, clearing of throat Primary medications given in ED for respiratory distress Bronchodilators [Sus-phrine (Epinephrine HCI) and Theophylline (Theo-dur)] ABG normals for the following: pH, pCO2, HCO3 pH: 7.35-7.45, pCO2: 34-45 mmHg, HCO3: 22-26 mEq/L Calculation of the heart rate using an EKG rhythm strip count the number of R-R intervals in the 30 large squares and multiply by 10 Intracranial hypertension from a traumatic brain injury is admitted to the trauma unit Elevated head of bed CPR-Arrange in other of priority Establish unresponsiveness Call for help Assess patent airway Assess pt carotid pulses Endometrial carcinoma receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator Wear a dosimeter film badge when in the client’s room 65-year-old female arrives in the ER with shortness of breath and chest pain, nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided The client would not be able to prove malpractice in court Deep vein thrombosis on heparin protocol based on a tPTT of 65 to 95 seconds. The current PTT result is 35 seconds Increase the rate of the heparin infusion Calculate the rate of this rhythm strip (It should be 90-100 depending on which set of 6 squares you use) A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol) Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine (Mucomyst) For increase magnesium level Give calcium gluconate Patient admitted with a Dx of diabetic ketoacidosis (DKA) with scant urinary output, K+2.5 mEq/l, pH of 7.26, T 98ºF, HR 128 bpm, RR 36, and BP 90/52 Pottasium IV at 20 mEq/250 ml over 1 hour Irregular respiratory rate with periods of apnea lasting 10 to 15 seconds Apply supplemental O2 The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85% Administer oxygen by face mask Doing CPR on intubated client with palpable pulse during 2-min cycle of chest compressions, absent breath sounds over left lung prepare for the endotracheal tube to be repositioned Unresponsive client who ingested an unknown number of meperidine (DEMOROL) 50mg tablets. Naloxone (NARCAN) 0.4mg IV is administered, and the client is now responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse Difficulty in arousing Patient in the MICU. What problem is a client probably experiencing who has an easily obliterated radial pulse and below-normal pressures, (BP), (CVP), (PAP), and pulmonary under pressure Hypovolemic shock PRI interval depolarization and repolarization Which is the highest for carcinogenic shock traumatic amputation from the groin down (there one of the choice a pt w/ gunshot wound to the chest and abdomen) *HESI HINT: if Cardiogenic shock exits in the presence of pulmonary edema (ex. from pump failure), position pt to reduce venous return (high fowler’s w/ legs down) in order to reduce further venous return to the left ventricle Patient with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick-release tie Reposition the restraints ties, securing them to the bed frame Nursing home patient admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 the nurse is running behind schedule (Zosyn) over 30 minutes q8 hours first During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of sustaining an epidural bleed “Was your husband knocked out by the blow” CPR for a pregnant lady Heimlich w/ chest compression *HESI HINT: At 20wks gestation & beyond, the gravid uterus should be shifted to the left by placing the women in a 15-30 degree angled, left lateral position or by using a wedge under her right side to tilt her to her left Patient has received 250 ml of 0.9% normal saline through the IV line in the last hour and is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. Decrease the saline to keep-open rate In EKG reading which complex represents depolarization of the ventricles QRS complex The risk for metabolic shock syndrome Toxic Shock Syndrome 23 year-old male brought to the ER by a group of fraternity brothers after a hazing event at the university. Blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3 Initiate IV access using Lactated Ringer’s solution 1000ml with thiamine 100mg The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane A yellow disaster tag means critical injuries and require immediate intervention Electrical burn pt put him in a cardiac telemetry monitor A pt on a trachea/endotrach with gurgling sound always pick suctioning