HESI Critical Care Exam
.Prior to a cardiac catheterization, which activity must the nurse have the customer practice?
A. Remain motionless for 5 minutes.
B. Flexing hips and knees bilaterally.
C. Valsalva's maneuver and coughing.
D. Talking while on foot on a treadmill - ANS-C. Valsalva's maneuver and coughing.
RATIONALE:
Before the cardiac catheterization, the customer ought to practice strategies (e.G., Valsalva's
maneuver, coughing, deep respiratory) that will be used throughout the method (B). The client
have to preserve the leg straight, now not (A), for the prescribed quantity of hours publish
cardiac
catheterization to prevent bleeding from the arterial access site. (C) isn't used in this process.
The patron may be requested to change role all through the technique, so (D) isn't important.
1.A consumer who has energetic tuberculosis (TB) is admitted to the medical unit. What motion
is most
vital for the nurse to implement?
A. Fit the purchaser with a respirator masks.
B. Assign the consumer to a terrible air-drift room.
C. Don a smooth gown for client care.
D. Place an isolation cart in the hallway - ANS-Assign the customer to a poor air-waft room
RATIONALE:
Active tuberculosis requires implementation of airborne precautions, so the client should be
assigned to a poor stress air-waft room (D). Although (A and C) ought to be implemented
for clients in isolation with touch precautions, it's far maximum important that air drift from the
room
is minimized whilst the customer has TB. (B) need to be implemented whilst the client leaves the
isolation environment.
2.A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse
determines the customer's apical pulse is 65 beats consistent with minute. What motion need to
the nurse
put into effect
subsequent?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare issuer.
D. Administer the drugs. - ANS-Administer the medicine
RATIONALE:
Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the coronary
heart price,
so the medicine need to be administered (C) because the client's apical pulse is more than 60.
,(A, B, and D) aren't indicated right now.
Three.The nurse is assessing a patron and identifies a bruit over the thyroid. This locating is
consistent
with which interpretation?
A. Hypothyroidism.
B. Thyroid cyst.
C. Thyroid most cancers.
D. Hyperthyroidism - ANS-Hyperthyroidism
Rationale:Hyperthyroidism (D) is an enlargement of the thyroid gland, regularly known as a
goiter, and a
bruit may be auscultated over the goiter due to an growth in glandular vascularity which
increases because the thyroid gland will become hyperactive. A bruit is not commonplace with
(A, B, and C).
A sixteen-year-antique male patron is admitted to the hospital after falling off a motorcycle and
sustaining a
fractured bone. The healthcare company explains the surgery needed to immobilize the
fracture.
Which motion should be applied to attain a legitimate informed consent?
A. Obtain the permission of the custodial determine for the surgery.
B. Notify the non-custodial parent to also sign a consent shape.
C. Instruct the purchaser sign the consent before giving medicinal drugs.
D. Obtain the signature of the patron's stepfather for the surgery. - ANS-A. Obtain the
permission of the custodial figure for the surgical operation.
RATIONALE:
The client is a minor and cannot legally sign his personal consent unless he's an emancipated
minor,
so the consent ought to be received from the mum or dad for this client, that's the custodial
parent
(B). (A) isn't always a legal alternative. A stepparent isn't always a prison dad or mum for a
minor except the child has
been adopted by way of the stepparent (C). The non-custodial determine does no longer want
to co-sign this form
(D).
A 56-12 months-old woman customer is receiving intracavitary radiation thru a radium implant.
Which
nurse must be assigned to care for this purchaser?
A. The nurse who's caring for any other customer receiving intracavitary radiation.
B. A nurse with Marfan's syndrome who's postmenopausal.
C. A nurse with oncology revel in who may be pregnant.
D. The nurse who is being concerned for every other consumer who has Clostridium difficile. -
ANS-B. A nurse with Marfan's syndrome who's postmenopausal.
RATIONALE:
A customer receiving intracavity radiation poses a radiation risk as long as the intracavity
,radiation source is in area. A nurse's capacity to care of this purchaser is not laid low with
Marfan's
syndrome (B), that's a hereditary ailment of connective tissues, bones, muscle groups,
ligaments
and skeletal systems. The goal is to restriction someone team of workers member's exposure to
the calculated
time span based at the half-lifestyles of radium, which includes the quantity of mins at the
bedside per day,
so (A) must now not be assigned. (C) should now not be uncovered to the radiation because of
the viable
impact at the fetus. A radiation publicity decreases the immune reaction inside the consumer
who need to
not be exposed to the potential inadvertent transmission of an infectious organism (D).
A 6-yr-antique infant is alert but quiet whilst delivered to the emergency middle with periorbital
ecchymosis and ecchymosis in the back of the ears. The nurse suspects potential child abuse
and keeps to evaluate the child for additional manifestations of a basilar skull fracture. What
evaluation finding might be consistent with a basilar cranium fracture?
A. Hematemesis and stomach distention.
B. Asymmetry of the face and eye actions.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm. - ANS-Rhinorrhoea or otorrhoea with Halo
signal.
RATIONALE:
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis at the back of the ear over
the
mastoid method) are each signs and symptoms of a basilar cranium fracture, so the nurse ought
to examine for viable
meningeal tears that happen as a Halo signal with CSF leakage from the ears or nostril (D). (A)
is
constant with orbital fractures. (B) happens with wrenching traumas of the shoulder or arm
fractures. (C) occurs with blunt belly injuries.
A 63-yr-vintage girl purchaser whose husband died one month ago is seen inside the psychiatric
medical institution. Her daughter tells the nurse that her mother is consuming poorly, sleeps little
or no at night time, and keeps to set the table for her deceased husband. What nursing hassle
pleasant describes this trouble?
A. Confusion associated with latest dying of cherished one.
B. Unresolved anger related to demise of husband.
C. Delayed grief response associated with loss of life of husband.
D. Denial related to the lack of a cherished one - ANS-D. Denial associated with the loss of a
loved one.
RATIONALE:
Based on the facts provided, (C) is the nice nursing diagnosis. This customer is showing signs
and symptoms
, of anxiety and the ache is simply too remarkable for her to acknowledge, so she is denying the
state of affairs.
Although she may seem harassed (A), she is simply trying to address the ache via the
protection mechanism of denial. (B) happens after 12 months or longer following the loss. The
consumer's
husband died one month ago. (D) and despair are often associated, and depression is every so
often
described as unexpressed anger. However, this consumer has no longer stated her loss (denial)
and
the anger is not but realized.
A nine-year-old is hospitalized for neutropenia and is placed in opposite isolation. The child asks
the nurse, "Why do you have to put on a robe and mask while you are in my room?" How have
to
the nurse respond?
A. "To protect you because you can get an infection very effortlessly."
B. "Your condition can be spread to workforce and different clients within the medical institution."
C. "There are many sorts of bacteria and germs inside the hospital."
D. "After taking medication for twenty-four hours a robe and masks won't be wanted." - ANS-A.
"To guard you because you may get an infection very without problems."
RATIONALE:
Reverse isolation precaution put into effect measures to protect the patron from publicity to
microorganisms from others (B). Although microbes are time-honored in all environments, (A)
does
not correctly solution the child's question. Reverse isolation need to be implemented till the
client's white blood cellular increases (C). Neutropenia on this infant does not area others (D) at
danger
for infection.
A baby is receiving preservation intravenous (IV) fluids on the rate of 1000 mL for the primary
10
kg of frame weight, plus 50 mL/kg in line with day for each kilogram between 10 and 20. How
many
milliliters according to hour ought to the nurse program the infusion pump for a child who weighs
19.Five kg?
(Enter numeric value best. If rounding is needed, round to the closest whole number.)
A. 24
B. 61
C. Seventy three
D. 58 - ANS-B. Sixty one
RATIONALE:
The system for calculating day by day fluid requirements is: 0 to 10 kg, one hundred mL/kg
according to day; or 10 to
20 kg, a thousand mL for the primary 10 kg of frame weight plus 50 mL/kg in keeping with day
for every kilogram
