HESI Critical Care Test Bank (HESI)

1. What assessment findings should he nurse document in the electronic medical record for a client who is experiencing autonomic dysreflexia after a TANSWER-4 spinal cord injury ANSWER-Severe hypertension, diaphroresis, and flushing above the lesion 2. As the nurse is turning a client with a chest tube, the chest tube becomes dislodged from the pleural space. What action should the nurse take first? ANSWER-Have the client exhale forcefully and tape 3 sides of a sterile gauze over the in...