HESI RN EVOLVE Critical Care Practice Quastion
&Answer 100%Answered
-A client who has experienced trauma is admitted to the intensive care unit (ICU). The
nurse's initial assessment findings include a Glasgow Coma Scale score of (3), pupils
fixed and dilated with an absence of corneal reflex, blood pressure of 80/30 mmHg, core
temperature of 95.7°F (35.4° C). The client's spouse asks the nurse when the client will
wake up. How should the nurse respond?
A) "Your spouse's condition indicates irreversible damage."
B) "Let me contact the health care provider to answer your questions."
C) "Each person is different and we need to wait and see what happens."
D) "I need to initiate the volume expanders and warming blanket to stimulate a
response."
((answers))B)
let me contact the health care provider to answer your questions.
-The nurse is caring for a client who is recently extubated in the post anesthesia care
unit (PACU). The client has humidified oxygen per mask and suddenly develops stridor
and respiratory difficulty. Which action should the nurse implement?
A) Call a rapid response team for emergency airway management.
B) Encourage the client to take deep breaths, cough, and expectorate.
C) Increase the flow rate of the humidified oxygen.
D) Suction the client's mouth and oropharynx thoroughly.
((answers))A) Call a rapid response team for emergency airway management
,-An older client is admitted to the intensive care unit after a small bowel resection. The
postoperative prescriptions include a patient-controlled analgesia (PCA) device with
morphine titrated per protocol. Which information should the nurse provide the client
about the use of the PCA?
A) Push button when pain is first experienced instead of waiting until pain is unbearable.
B) Family members or visitors can press the button when the client grimaces in pain.
C) Press the button every 15 minutes even when pain is not present.
D) Delay pressing the button until the pain level is 8 on a scale of 1 to 10.
((answers))A)
Push button when pain is first experienced instead of waiting until pain is unbearable
-The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically
ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How
should the nurse interpret this blood gas?
A) Respiratory acidosis.
B) Respiratory alkalosis.
C) Metabolic acidosis.
D) Metabolic alkalosis.
((answers))B) Respiratory alkalosis
-According to the paramedic's report, the victim of a motor vehicle collision was sitting in
the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic
light when the vehicle was hit on the left side by another vehicle traveling at speeds
exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L)
side of thorax and body. The significant assessment findings include: weak and thready
pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is
diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is
present in the (L) flank area and progresses towards the abdomen. Vital signs are
temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22
breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2
lpm O2 via nasal cannula.Which potential injuries should the triage nurse assess?
(Select all that apply.)
A) Flailed ribs.
B) Fractured liver.
C) Ruptured spleen.
D) Cardiac tamponade.
E) Tension pneumothorax
((answers))B)
Fractured liver
, C) Ruptured spleen
-A client reports to the nurse feeling achy and weak, being tired and coughing all the
time, frequent headaches and experiencing night sweats. The client's assessment is
significant for crackles scattered throughout the lungs, dependent peripheral edema
+3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110
beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg
with a mean arterial pressure of (75). Which diagnostic procedure should the nurse
prepare to do first?
A) Metabolic panel with electrolytes.
B) Complete blood count.
C) Liver function test.
D) Blood culture.
((answers))D) Blood culture
-The nurse is caring for a client admitted to the intensive care unit with a traumatic brain
injury from a motor vehicle collision. The client is experiencing increased intracranial
pressure (ICP). The healthcare provider explains to the family that the client needs to go
to surgery for decompressive craniectomy. Which information should the nurse explain
to the client?
A) An over-lying cranial bone flap is removed to allow swelling brain tissue to expand.
B) The procedure uses a magnetic resonce imaging-guided laser ablation.
C) An opening into the skull is made to remove damage tissue.
D) A burr hole is drilled through the cranial bones to evacuate blood.
((answers))A)
An over-lying cranial bone flap is removed to allow swelling brain tissue to expand
-A client's cardiac rhythm reveals peaked "T" waves, a widening "QRS" complex and
the flattening of "P" waves. Which medication should the nurse administer?
A) Phosphate IV push.
B) Furosemide IV push.
C) Calcium gluconate IV push.
D) Diluted potassium IV push.
((answers))C) Calcium gluconate IV push
-The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated.
The ABG results are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the
nurse interpret this blood gas?
&Answer 100%Answered
-A client who has experienced trauma is admitted to the intensive care unit (ICU). The
nurse's initial assessment findings include a Glasgow Coma Scale score of (3), pupils
fixed and dilated with an absence of corneal reflex, blood pressure of 80/30 mmHg, core
temperature of 95.7°F (35.4° C). The client's spouse asks the nurse when the client will
wake up. How should the nurse respond?
A) "Your spouse's condition indicates irreversible damage."
B) "Let me contact the health care provider to answer your questions."
C) "Each person is different and we need to wait and see what happens."
D) "I need to initiate the volume expanders and warming blanket to stimulate a
response."
((answers))B)
let me contact the health care provider to answer your questions.
-The nurse is caring for a client who is recently extubated in the post anesthesia care
unit (PACU). The client has humidified oxygen per mask and suddenly develops stridor
and respiratory difficulty. Which action should the nurse implement?
A) Call a rapid response team for emergency airway management.
B) Encourage the client to take deep breaths, cough, and expectorate.
C) Increase the flow rate of the humidified oxygen.
D) Suction the client's mouth and oropharynx thoroughly.
((answers))A) Call a rapid response team for emergency airway management
,-An older client is admitted to the intensive care unit after a small bowel resection. The
postoperative prescriptions include a patient-controlled analgesia (PCA) device with
morphine titrated per protocol. Which information should the nurse provide the client
about the use of the PCA?
A) Push button when pain is first experienced instead of waiting until pain is unbearable.
B) Family members or visitors can press the button when the client grimaces in pain.
C) Press the button every 15 minutes even when pain is not present.
D) Delay pressing the button until the pain level is 8 on a scale of 1 to 10.
((answers))A)
Push button when pain is first experienced instead of waiting until pain is unbearable
-The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically
ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How
should the nurse interpret this blood gas?
A) Respiratory acidosis.
B) Respiratory alkalosis.
C) Metabolic acidosis.
D) Metabolic alkalosis.
((answers))B) Respiratory alkalosis
-According to the paramedic's report, the victim of a motor vehicle collision was sitting in
the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic
light when the vehicle was hit on the left side by another vehicle traveling at speeds
exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L)
side of thorax and body. The significant assessment findings include: weak and thready
pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is
diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is
present in the (L) flank area and progresses towards the abdomen. Vital signs are
temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22
breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2
lpm O2 via nasal cannula.Which potential injuries should the triage nurse assess?
(Select all that apply.)
A) Flailed ribs.
B) Fractured liver.
C) Ruptured spleen.
D) Cardiac tamponade.
E) Tension pneumothorax
((answers))B)
Fractured liver
, C) Ruptured spleen
-A client reports to the nurse feeling achy and weak, being tired and coughing all the
time, frequent headaches and experiencing night sweats. The client's assessment is
significant for crackles scattered throughout the lungs, dependent peripheral edema
+3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110
beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg
with a mean arterial pressure of (75). Which diagnostic procedure should the nurse
prepare to do first?
A) Metabolic panel with electrolytes.
B) Complete blood count.
C) Liver function test.
D) Blood culture.
((answers))D) Blood culture
-The nurse is caring for a client admitted to the intensive care unit with a traumatic brain
injury from a motor vehicle collision. The client is experiencing increased intracranial
pressure (ICP). The healthcare provider explains to the family that the client needs to go
to surgery for decompressive craniectomy. Which information should the nurse explain
to the client?
A) An over-lying cranial bone flap is removed to allow swelling brain tissue to expand.
B) The procedure uses a magnetic resonce imaging-guided laser ablation.
C) An opening into the skull is made to remove damage tissue.
D) A burr hole is drilled through the cranial bones to evacuate blood.
((answers))A)
An over-lying cranial bone flap is removed to allow swelling brain tissue to expand
-A client's cardiac rhythm reveals peaked "T" waves, a widening "QRS" complex and
the flattening of "P" waves. Which medication should the nurse administer?
A) Phosphate IV push.
B) Furosemide IV push.
C) Calcium gluconate IV push.
D) Diluted potassium IV push.
((answers))C) Calcium gluconate IV push
-The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated.
The ABG results are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the
nurse interpret this blood gas?
