HESI RN EVOLVE CRITICAL CARE PRACTICE QUIZ WITH CORRECT SOLUTIONS

HESI RN EVOLVE CRITICAL CARE PRACTICE QUIZHESI RN EVOLVE CRITICAL CARE PRACTICE QUIZ 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." 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. 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. A) Push button when pain is first experienced instead of waiting until pain is unbareable 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. 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 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. 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. 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. 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? A) Fully compensated respiratory acidosis. B) Fully compensated respiratory alkalosis. C) Fully compensated metabolic acidosis. D) Fully compensated metabolic alkalosis. A) Fully compensated respiratory acidosis The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The ABG results are pH - 7.17; paCO2 - 70 mmHg; HCO3 - 30 mEq/liter. How should the nurse interpret this blood gas? A) Respiratory acidosis. B) Respiratory alkalosis. C) Metabolic acidosis. D) Metabolic alkalosis. A) Respiratory Acidosis A client in the intensive care unit receives a STAT prescription for mannitol IV for cerebral edema post closed head injury. Which action should the nurse implement when preparing to administer the medication? A) Use a filtered needle to draw up the medication and an in-line filter during infusion. B) Place atropine at bedside for use if the client has bradycardia during administration. C) Hyperventilate the client prior to administration to decrease intracranial pressure. D) Stop all sedation while mannitol is being administered per secondary infusion. A) Use a filtered needle to draw up the medication and an in-line filter during infusion. The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which intervention should the nurse implement? A) Assess for signs of cardiac tamponade. B) Begin chest compressions at 120 per minute. C) Check for responsiveness with sternal rub. D) Obtain a STAT 12 lead electrocardiogram. B) Begin chest compressions at 120 per minute The nurse is caring for a client who is prescribed a potassium-sparing diuretic and has a potassium level of 6.1 mEq/L (6.1 mmol/L). Which intervention should the nurse perform? A) Obtain a 12-lead electrocardiogram (ECG). B) Call a rapid response. C) Insert an intravenous (IV) line. D) Schedule a cardiac catheterization. A) Obtain a 12-lead electrocardiogram (ECG) The nurse is caring for a client who underwent surgical repair of the aorta after sustaining injuries in a fall. Which finding indicates improved blood flow after the surgery? A) Movement of lower extremities. B) Decreased urinary output. C) Maintained weight. D) Blood pressure 90/50. A) Movement of lower extremities The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries sustained in a motor vehicle collision. The client has a Glasgow Coma Score of 6. Which intervention should the nurse prepare for the client? A) Intubation with mechanical ventilation. B) Nasogastric tube placement. C) Advanced cardiac life support. D) 12-lead electrocardiogram (ECG). A) Intubation with mechanical ventilation The nurse is caring for a client in the critical care unit who is experiencing end-stage chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at 40 L/minute via Vapotherm. The healthcare provider informs the client and family that there is no further treatment available for the COPD. Which intervention should the nurse recommend that is most beneficial to the client and family? A) Hospice services. B) Intubation with mechanical ventilation. C) Organ donation. D) Home health care. A) Hospice services A client diagnosed with an end-stage terminal illness has decided to discontinue treatment. The client has become very detached and does not want to participate in the plan of care. Which action should the nurse implement first? A) Initiate a referral for a mental health consultation. B) Encourage the client to participate in their plan of care. C) Review the client's medical record for documented religious preference. D) Contact the hospital chaplain to provide spiritual counseling and guidance. C) Review the clients medical record for documented religious preferences The nurse assists the healthcare provider with the insertion of a pulmonary artery (PA)catheter for a client presenting with cardiogenic shock. Which action is most important for the nurse to take to prevent life-threatening complications from pulmonary artery monitoring? A) Fast flush the PA distal port for no more than 2 seconds. B) void infusing blood products through the PA catheter. C) Clear pressure tubing of any blood after with-drawing a sample. D) Maintain 300 mmHg pressure around the bag attached to the tubing. A) Fast flush the PA distal port for no more than 2 seconds A client who returns to the postoperative unit after a total thyroidectomy suddenly becomes short of breath and develops stridor. What action should the nurse implement first? A) Call the rapid response team for emergency assistance. B) Encourage the client to relax as respiratory effort eases. C) Document the findings and monitor the client hourly. D) Call respiratory therapy to provide cool mist oxygen per mask. A) Call the rapid response team for emergency assistance The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? A) Change in level of consciousness. B) Increase in urinary output. C) Onset of Kussmaul respirations. D) Decrease in serum potassium level. A) Change in level of consciousness Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to water seal. The client is using the incentive spirometer hourly while awake. Which assessment finding warrants intervention by the nurse? A) Serosanguineous fluid in collection container. B) Fluid fluctuation in tubing with respirations. C) Water seal level2 cm below the water seal fill line. D) Report of chest tube insertion site tenderness. C) Water seal level2 cm below the water seal fill line. The nurse is analyzing an arterial blood gas (ABG) of a client who has a nasogastric tube to low suction. The ABG results are pH - 7.48; paCO 2 - 50 mmHg; HCO 3 - 27mEq/liter. How should the nurse interpret this blood gas? A) Partially compensated respiratory acidosis. B) Partially compensated respiratory alkalosis. C) Partially compensated metabolic acidosis. D) Partially compensated metabolic alkalosis. D) Partially compensated metabolic alkalosis. A chest X-ray is prescribed for a client with possible adult respiratory distress syndrome (ARDS). Which radiographic finding represents the pathological processes of pulmonary edema and consolidation of the lungs as ARDS progresses ? A) White-out appearance. B) Infiltrates. C) Calcified cavities. D) Multiple nodules. A) White-out appearance. A client placed on hospice care is admitted for palliative radiation treatments to the neck. Which assessment should the nurse identify as a priority? A) Pain assessment. B) Respiratory assessment. C) Cardiovascular assessment. D) Integumentary assessment. A) Pain assessment. A client reports shortness of breath and chest pressure radiating down the left arm. The client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first? A) Give0.3 mg nitroglycerin sublingual. B) Administer4 mg IV morphine sulfate. C) Measure the ST segment height. D) Infuse 0.9% sodium chloride bolus. D) Infuse 0.9% sodium chloride bolus The nurse is collecting a sample for arterial blood gases (ABGs) for a client with hypoxia due to cardiomyopathy. Which should the nurse assess prior to obtaining the arterial blood sample? A) Ulnar blood flow. B) Apical heart rate. C) Oxygenation level. D) Breath sounds. A) Ulnar blood flow The health care provider has determined that a client has irreversible brain damage with subsequent brain death. Organ donation is discussed with the family. Which action should the nurse take prior to contacting the organ procurement organization (OPO)? A) Obtain informed consent. B) Disconnect the ventilator. C) Remove all jewelry. D) Contact the medical examiner. A) Obtain informed consent The nurse is caring for a client admitted to the surgical intensive care unit (SICU) on the first postoperative day after a kidney transplantation. Which intervention should the nurse include in the plan of care to prevent hypovolemia? A) Give IV fluids on a 1:1 ratio from output. B) Administer loop diuretics. C) Increase sodium intake. D) Provide sports drinks for hydration. A) Give IV fluids on a 1:1 ratio from output. A client who is hypotensive is receiving an infusion of dopamine 10 mcg/kg/minute IV through a peripheral line. The client begins to report burning at the IV site. Which action should the nurse implement? A) Stop the infusion and notify the healthcare provider of the findings. B) Check the line for blood return and irrigate the peripheral IV catheter. C) Apply a cold compress to the site and continue the infusion's rate. D) Slow the infusion rate and add a secondary IV of 0.9% sodium chloride. A) Stop the infusion and notify the healthcare provider of the findings. A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription should the nurse implement first? A) Obtain serum sodium levels every 4 hours. B) Provide oral sodium chloride supplements. C) Monitor fluid restriction and document hourly intake and output. D) Initiate normal saline IV at 100 mL/hour. A) Obtain serum sodium levels every 4 hours A client who is critically ill requests to receive the Sacrament of the Anointing of the Sick. Which clergy member should the nurse contact? A) Rabbi. B) Priest. C) Sharma. D) Ayatollah. B) Priest A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern? A) Kussmaul respirations. B) Cheyne stokes respirations. C) Apnea. D) Orthopnea. A) Kussmaul respirations The nurse is caring for a client in the critical care unit who has a pituitary tumor an