Critical Care HESI Questions and Answers 100% Verified

Critical Care HESI Questions and Answers 100% Verified 1 . What assessment findings should he nurse document in the electronic medical record for a client who is experiencing autonomic dysreflexia after a T-4 spinal cord injury? Ans: 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? Ans: Have the client exhale forcefully and tape 3 sides of a sterile gauze over the insertion site 3 . The nurse plans to administer a low dose prescription for dopamine (Intropin) to a client who is in septic shock. Which physiological parameter should the nurse use to evaluate a therapeutic response to dopamine? Ans: Urinary Output 4 . The nurse assesses a male client postoperatively who has an arterial line in the radial artery. Assessment findings include pallor, parastesia, and slow capillary refill in the client's right hand fingers. What action should the nurse plan? Ans: Notify the HCP 5 . A male client is admitted to the cardiac intensive unit with chest pain that began twelve hours ago. The nurse recognizes increased ventricular ectopy? Based on this assessment finding, what actions is most important for the nurse to implement? Ans: Initiate the unit's antiarrhythmic protocol if symptomatic. 6 . The nurse is assessing a client who was admitted 24 hours ago to the critical care unit following a motorcycle collision. Which client finding requires intervention by the nurse to reduce the risk for complication related to increased intracranial pressure? Ans: Change of PaCo2 to 55 mm Hg following ventilator setting adjustments 7 . A client is receiving cardiopulmonary resuscitation. After asystole is confirmed in two leads and sending for the transcutaneous pacemaker, which intravenous medication should be administered? Ans: Epinephrine 8 . The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow coma scale is 9. What information is most important for the nurse to determine? Ans: The client's previous GCS score 9 . The healthcare provider prescribes a STAT computerized tomography without contrast for a client who is exhibiting signs of an acute change in the level of consciousness. The nurse is caring for two additional intensive care clients and has an unlicensed assistive personnel assigned to assist with the delivery of care. What action should the nurse take? Ans: Administered the schedule medications prior to transporting the client to CT scan. 10 . The healthcare provider prescribes and IV fluid bolus for a client who was admitted two hours ago to the ICU because of adrenal crisis. The client is confused and uncooperative. The nurse has attempted two times to obtain IV access without success. Which intervention should the nurse implement first? Ans: Ask another nurse to attempt insertion of IV 11 . Arterial blood gas results indicate that a client with respiratory failure who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm H2O and oxygen concentration of 30%. Which action should help correct the client's acidosis? - Provide manual resuscitation - Increase oxygen concentration - Decrease the pressure support - Increase the ventilator rate Ans: - Provide manual resuscitation 12 . An adult present to the emergency department with complaints of epigastric discomfort. The client reports shortness of breath and fatigue for the past two days. Which action should the nurse implement first? - Place leads for an electrocardiogram - Administer an antacid per protocol - Obtain a blood specimen for cardiac enzymes - Ask if taking non-steroidal anti-inflammatory drugs Ans: - Place leads for an electrocardiogram 13 . The nurse identifies the collaborative problem of potential electrolyte imbalance in a patient with acute pancreatitis. What assessment findings alert the nurse to an electrolyte imbalance associated with acute pancreatitis? Ans: - Muscle twitching and digit numbness 14 . A client who sustained severe liver laceration in a motorcycle collision is transported to ICU following a segmental resection of the liver. One hour later, the nurse notes that the client is hemorrhaging from surgical site. What action should the nurse take? Ans: - Prepare the client to return to the operating room 15. A comatose client requires suctioning q4h. What is the best parameter for the nurse to use to determine effectiveness of tracheal suctioning? - Arterial blood gas levels - Serum hemoglobin - Pulse rate/HR - Capillary refill - Arterial blood gas levels 16. The nurse is assisting the healthcare provider during the insertion of a pulmonary artery (PA) catheter into a client with heart failure. While the PA catheter is advanced the nurse observes the monitor. Which sequence of pressure readings on the hemodynamic monitor indicate the PA is advancing? Ans: - Right atrium, right ventricle, pulmonary artery, and pulmonary artery wedge 17. A male client is admitted to the neurological unit. He has sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse? Ans: - Respirations are shallow, labored, and 14 breaths/min 18. The nurse is calculating fluid resuscitation for a young adult male who was burned in a boating accident at 12 noon and is seen in the emergency center at 2 pm. The HCP determines that the client has burns over 30% of his body, mainly on the arms and chest. Using the Parkland formula for fluid resuscitation the client is to receive 7, 000 ml of fluids in 24 hours. Which goal should the nurse establish for this client's plan of care? Ans: - By 8pm, the client will have received 3,500 ml of fluids 19. A male client with an implanted cardioverter/defibrillator reports to the home health nurse that he feels dizzy when the device discharges. What intervention is most important for the nurse to implement? Ans: - Advice the client to lie down immediately when dizziness occurs 20. A female client is admitted with a blunt chest injury following a motor vehicle collision. She is confused, hypotensive, cyanotic, and has distant heat sounds. Which nursing assessment finding requires immediate intervention? Ans: -Pulmonary congestion 21. Name the ECG strip Ans: Atrial Flutter: 22. After and endotracheal tube is place for a client who requires mechanical ventilation, which intervention should the nurse implement first? Ans: - Auscultate for breath sounds bilaterally in all lung fields 23. A client's ventilator has indicated progressively higher levels of pressure within the past 3 minutes. The pulse oximeter shows diminishing oxygenation saturation from 97% to 92 % despite the maintenance of all settings: FiO2 of 50 %, IMV 18 and peep 5 cm. The endotracheal tube is correctly place and taped securely. What action should the nurse take? ANs: - Suction the ET tube 24. Nitroglycerin 30 mcg/min is prescribed for a client who is admitted with chest pain. Nitroglycerin 100 mg is dispensed in a solution of 250ml of D5W. The nurse should program the infusion pump to deliver how many ml/hr. (Round to the nearest tenth) ... 25. An elderly client had coronary artery bypass surgery today. Following surgery, the IV infusion pump malfunctioned, and the client inadvertently received a liter of 0.9% normal saline over the past 45 minutes. Which physical assessment is most important for the nurse to make at this time? Ans: - Determine if the client's jugular vein is distended 26. Two hours after the admission to the ICU following a motorcycle accident that caused chest trauma, the client's hemodynamic monitors begin to sound alarms. Which assessment findings warrant immediate intervention by the nurse? (Select all that apply) A. Multiple artifacts occurring on the telemetry B. Direct arterial blood pressure is 100/60 C. Swan Ganz pulmonary artery catheter measures Sv02 at 50% D. Sinus tachycardia at 120 beats/minutes E. Pulmonary artery wedge pressure from swan ganz elevated ... 27. While admitting a male client with upper extremity, chest, and abdominal burns, the client complains of difficulty swallowing and the nurse observes him drooling. Which intervention should the nurse implement first? A. Assess pupillary reactions to light B. Determine time of last oral intake C. Measure and record abdominal growth D. Auscultate over mainstream bronchi D. Auscultate over mainstream bronchi 28. The vital signs for a client with heart failure who is admitted to the ICU unit include: temperature 98.6 F, pulse 125 beats/min, respirations 22 breaths/min, and BP/. The nurse determines the client's central venous pressure and pulmonary artery wedge are elevated. Which intervention should the nurse implement? Ans: - Give an IV bolus of ml normal saline 29. A female client who had gastric bypass surgery 3 days ago is admitted to the ICU complaining of shortness of breath and chest pain. Her oxygen saturation rate is 88% on 100% non-rebreather. Which intervention should the nurse implement? Ans: - Prepare for oral intubation 31. A client with end stage liver failure was admitted to the intensive care unit two days ago after three episodes of bloody emesis. No further bloody emesis has occurred since admission. The nurse obtains an order for a liquid diet when the client requests something to eat. Which intervention should the nurse implement? - Avoid foods with red dye 32. A client arrives in the emergency department via ambulance with injuries from being hit by a bus. Vital signs admission are : BP 126/70 mm Hg, heart rate 100 beats/min, respirations 28 breaths/min, temperature 99 F. Bloody drainage is noted at the client's left ear canal. What should the nurse do to assess for possible basilar skull fracture and cerebrospinal fluid leak? Ans: - Gently dab blood from the ear with a sterile gauze and observe for a halo 33. A client involved in a motor vehicle collision is admitted to the trauma intensive care unit. Which assessment finding warrants immediate intervention by the nurse? Ans: -Absence of right upper lungs sound 34. A client is brought to the emergency center with a gunshot would with a bullet entry at the level of the last cervical and first thoracic spinal cord (C8 and T1). The client is able to move the upper arms. To further assess the client's spinal nerve function. What action should the nurse implement? Ans: - Ask the client to grasp an object or form a fist 35. A client is admitted to the ICU with meningitis complicated by syndrome of inappropriate antidiuretic hormone (SIADH). The client is complaining of abdominal cramping and headache. To preventing life threatening seizures, which intervention is most important for the nurse to implement? Ans: - Monitor serum sodium 36. The nurse is caring for a client who hemorrhaged postoperatively, and is in the early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock? - Increased pulse rate, lowered systolic pressure, peripheral extremity mottling 38. A client has a chest tube connected to a closed water seal drainage system with the suction. What equipment should the nurse always have available at the client's beside? Ans: -Sterile gauze dressing 39. When a client's mechanical ventilator starts to alarm what is the priority nursing action? Ans: Note the client's o2 sat rate 40. The nurse is caring for a client who is experiencing left ventricular failure. Which medication provides the greatest vasodilation effect? Ans: - Morphine sulfate 41. A postoperative client is admitted to the ICU with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial cannula. Which finding indicates that the heparin infusion has achieved it therapeutic effect? Ans: - Intra-arterial cannula remains patent 42. A client is admitted to the critical unit with third degree complete heart block. A temporary transvenous pacemaker is inserted by the healthcare provider. An hour after pacemaker insertion, this device stops sensing the client's intrinsic heart rate. Which action should the nurse implement first? Ans: - Check the sensitivity control Term 1 / 162 The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? a) The client's previous GCS score b) When the client's stroke symptoms started c) If the client is oriented to time d) The client's blood pressure and respiration raTe a) The client's previous GCS score Rationale: The normal GCS is 15, and it is most important for the nurse todetermine if it abnormal score a sign of improvement or a deterioration in theclient's condition The nurses calculating fluid resuscitation for young adult male who was burned in a bloody accident at 1200 and is seen in the ER at 1400. The HCP determines that the client has burn over 30% of his body, mainly over his arms and chest. Using the Parkland formula for fluid resuscitation, the client is to receive 7000 mL of fluid in 24 hours. Which goal should the nurse establish for this clients plan of care? By 2000, the client will have received 3500 mL of fluid