HESI RN EVOLVE Critical Care Practice Quiz/ Latest 2022:2023/ Guaranteed A+ Guide
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Course
HESI RN EVOLVE Critical Care
Institution
Kaplan University
The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two inches above and left of the victim's xiphoid pr...
hesi rn evolve critical care practice quiz latest 20222023 guaranteed a guide
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HESI RN EVOLVE Critical Care Practice Quiz/ Latest 2022:2023/
Guaranteed A+ Guide
The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim
was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5
cm) in width. The "point of entry" of the stab wound is two inches above and left of the victim's
xiphoid process. Which vital organ(s) are at an increased risk of being in the direct path of
injury? Correct Answer: Heart
Lungs
Diaphragm
What way do females stab? Correct Answer: Downwards
What way do males stab? Correct Answer: Upwards
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? Correct Answer: Blood culture
Define: Infective endocarditis Correct Answer: Infection of the endocardial surface of the heart,
usually the heart valves
What indicates ineffective endocarditis? Correct Answer: Edema & S1/S3 sounds
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. Correct Answer: Fractured liver & ruptured
spleen
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly ventilated.
The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse
interpret this blood gas? Correct Answer: Respiratory alkalosis
Define: Respiratory alkalosis Correct Answer: HCO3 & pH is increased while the CO2 is
decreased
, What is the effect if blood sugar continues to rise? Correct Answer: Change in level of
consciousness
What precaution should a patient be on with a high sodium? Correct Answer: Seizure
precautions
Why do people with diabetes have an increased urinary output? Correct Answer: Low ADH
What is the effect of a low ADH? Correct Answer: Dehydration & increased serum Sodium
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? Correct Answer: Obtain serum sodium every 4
hours
The nurse is caring for a client who is demonstrating signs of impending death. The family is
experiencing emotional distress as the client's condition declines. Which information should the
nurse provide the family to facilitate the process? Correct Answer: Encourage the family to give
the patient permission to die
The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven
and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L,
and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: Intercostal muscle contraction
Define: Intercostal muscle contraction Correct Answer: Critical sign of respiratory muscle
fatigue which is likely to lead to acute respiratory failure
Define: Cistacurium Correct Answer: Paralytic during surgery
A client who experienced an intracranial hemorrhage is receiving cistracurium to induce a
pharmacological state of paralysis. Which intervention should the nurse implement during the
therapeutic paralysis? Correct Answer: Administer a sedating medication
A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted.
Which finding should the nurse observe for during the immediate hours after insertion? Correct
Answer: Beck's Triad
What are pacemakers & defibrillators able to cause? Correct Answer: Bleeding into the
pericardial sac which causes a high risk for cardiac tamponade
Define: Cardiac tamponade Correct Answer: Blood or fluid fills the space between the heart &
its sac
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