lOMoAR cPSD| 30970899

Critical CARE HESI EXIT Form

A, B &C Practice Questions
and Correct Answers
 1

FORM A
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

- 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?

- 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?

- 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?

- 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?

-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?
- 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?

- 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?

- 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?

-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?

- 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

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 of taking non-steroidal anti-inflammatory drugs )

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?

- 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?

- 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 measure the effectiveness
of tracheal suctioning?

-Arterial blood gas levels

-Serum hemoglobin

-Pulse rate/HR

-Capillary refill

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?

- 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?

-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?

-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?
 -Advice the client to lie down immediately when dizziness occurs

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cyanotic, and has distant heat sounds. Which nursing assessment finding requires immediate intervention?
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congestion

21.

ECG strip: Atrial Flutter: (this is the exact pic from the test)

22. After and endotracheal tube is place for a client who requires mechanical ventilation, which intervention should the
nurse implement first?

-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?

-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
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-Palpate the abdomen to detect presence of a fluid wave

-Determine if the client’s jugular vein is distended

-Check the moistness of the client’s mucous membrane

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

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?

-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?

-Prepare for oral intubation

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ntshdeoccxli/ent has asymmetrical chest excursion. What
-Determine the client’s endotracheal tube placement

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?
 -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?

-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?

-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?

-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

37. The nurse mixes 200 mg of Dopamine in 50 ml of D5W and plans to administer the solution at a rate of 8 mcg/kg/min
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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?

+Critical Care HESI+ -Sterile gauze dressing

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action?

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?

-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?

-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?

-Check the sensitivity control

43. I CANT REMEMBER

A. Obtain a 12 lead electrocardiogram
 FORM B

1). Pt has a long history of smoking. Pt comes in with sob. These are the ABG’s: pH 7.25,
PCO2 50, anD HCO3 24. What does the patient have?

• Resp. Acidosis
*Remember: If the CO2 is high it will always be resp. acidosis
2). Female comes in the ED and says that her “heart is pounding outside of her chest. Client is
in SVT. What is the nursing intervention?

• Coach client in relaxation and deep breathing.

3). This is an insulin PROTOCOL question. You will be given a protocol that you need to follow
by the MD. The pt insulin is infused at 5 units/hr and her current glucose reading is 165. What
should you do?

• Increase drip by 1 unit/hour

4). Calculate question. The number will be 1,500,000 IU, in 500mL of 0.9% NS.

• 33
5). DKA math question

• 1,000mL NS with 30 Meq of Sodium

6). Older client comes in with CAP and SpO2 89%. What is the priority intervention?

• Assist client with turning, coughing, and deep breathing

7). Pt received an ETT 7 days ago and is currently on 50% O2. The pt is currently anxious and
hyperventilating. What is the priority intervention?

• Auscultate lungs
8). Client has not been taking cortisone for either 2 weeks or 2 months and husband brings her
into the ED. Husband states that she has not been feeling well and that she needed help
getting ready today. (Patient has SIAH). What should you do?

• Initiate fall precautions

*Remember that SIAH causes seizures so you have to put the client on fall precaution
9). UAP is coming to assist a nurse in a situation where the pt is having SVT and the nurse has
to prepare for cardioversion. What task can the UAP do?

• Bring Resuscitation cart to the bedside

10). A pt has a cardioversion due to uncontrolled A Fib. What vital shows that the cardioversion
was successful?
 • Normal sinus rhythm with hr 84
11). Pt has ortho surgery and 12 hrs after the surgery the patient is anxious and sob. What is
the nursing intervention?

• Position client on the left side

12). The pt is receiving dopamine. What do you have to monitor for while on this drug?
Monitor urinary output
13). During the insertion of a swan gans, what should the nurse do?

Monitor for dysrhythmias

14). Which of these vital signs are contraindicative of ICP?

• PaCO2 of 55
*Remember that normal PaCo2 should be between 35-45. When it increased, it will cause more
ICP.
15). There is a question about SIAH and normal lab values that would be associated with this
disease.

• HYPERkalimemia and HYPOnatremia

16). A pt has a Glasgow coma scale of 14. What should the nurse do?
Document the findings
17). When caring for a client on a ventilator which finding shows the airway is open?

• Bilateral breath sounds can be auscultated

18). Pt is in the ICU after a colon resection. The vital signs are: 135hr, temp 103, and BP of
88/65 and urine output of 10mL/ hr. What should the nurse do?

• Give a 500mL IV bolus challenge.

19). There will be another question just like 18. The scenario will be different but the BP will be
very low as well.

• The answer will be the same as 18 but it will not say challenge.
20). A client has syncopal episodes due to 3rd degree block. The patient receives a
transcutaneous pacemaker. The nurse observes that there are several episodes the pacemaker
fails to sense. What should the nurse do?
 • Increase the sensitivity
21). Which of these drugs are the strongest or most effective vasodilators?

• Lidocaine
22). There will be another math question. It’s mcg to mg. 4mcg/kg and client weighs 165 lbs.

• 3.5 mL/hr
23). A FEMALE falls down a flight of stairs and is having trouble walking and bearing weight.
The MD prescribes hydrocodone for pain and an xray. What should the nurse do?

• Have the client take a urine pregnancy test

24) , A pt with a chest tube has the tube dislodged from the pleural space. What is the nursing
intervention?

• Place an occlusive dressing with tape on 3 sides

25). A postoperative client is admitted to the ED with an Intra arterial (IA) canula. There is
heparin infusing at 2 units per mL. Which finding indicates the heparin has achieved therapeutic
use?

• The IA remain patent

26). A pt arrives to the ED with pain. Which description should prompt the nurse to suspect an
MI?

• Produces chest heaviness with left arm pain

27). What equipment should always be made available at the bedside for a pt with a chest
tube?

• Occlusive dressing
28). What things should be done to determine if an ETT tube is in place. This is the select all
that apply. There will be 3 answers.

• Chest Xray, the chest rises and falls bilaterally, and auscultate breath sounds
29). Pt comes in with SEVERE hypotension. What medication should you expect there to be a
prescription for?

• Amiodaron
30). A female client has been asystole for 20 minutes and there has been no change in the
client’s condition. The client is also intubated. What should the nurse do?

• Talk to the family members in a private area about desire to continue life support
31). A 47-year-old female client that comes in and thinks they have indigestion due to vigorous
workout. Which client problem has the highest priority?

• Decreased cardiac output 32). There will be an EKG strip.

• Prepare the client for a pericardiocentesis

33). A client is treated for MI that occurred less than 6 hrs ago. The MD suspects 100%
occlusion. What does the EKG show?

• Sinus Bradycardia, Q waves and ST elevation, and ORS lengthening

34). There will be a list of vital signs and the patient will come in 2 hours after being in pain.
What does the nurse suspect the patient to have?

• Acute Pancreatitis
35). Client has a pneumothorax and has a chest tube with NO fluctuation in the water seal.
What should the nurse do?

• Assess lung sounds

36). A male falls 20 feet and the nurse observes it. The client has no pulse. What should the
nurse do?

• Begin CPR 120 per 1 minute

37). There is an older woman patient that feels very weak and is having a hard time breathing.
She is leaning over while the nurse is doing her assessment and she can’t keep her head up.
What is the nursing intervention?

• Keep the client in high fowlers

38). There will be a question about a client that is on the ventilator. What nursing intervention
should be done so that the pt doesn’t develop VAP?

• Oral hygiene
39). You get a patient that is getting an ETT. The MD has sedated the pt and the pt has soft
restraints. What is the nursing intervention?

• Test to see if the pt is aggressive once the sedation has weened down
40). You have been trying to place an IV in a patient that is CONFUSED and ANXIOUS. What is
the best intervention?

• Notify MD for a restraint so that pt can get the IV they need 41). What do you do
PRIOR to drawing from and Arterial Line?

• Allen’s Test
42). There will be a question with vitals that is related to acute pancreatitis. It will ask what
should you monitor for?
• Cushing’s triad
 lOMoAR cPSD| 30970899

43). A pt diagnosed with acute pancreatitis is admitted to the ICU with a temp 102, PR 138, RR
32 and BP of 80/40. Which finding should the nurse report to the healthcare provider?
Hemorrhagic discoloration at the umbilicus
44). A pt comes in who was in a fire and the smoke was in her face. The pt states that they can
not breath. What is the priority nursing intervention?

• Auscultate broncus (trach)

45). A pt is on a ventilator and the vent is malfunctioning. What is the nursing intervention?

• Bag the pt manually

46). A pt is turning and the chest tube falls out. What should the nurse tell the pt to do?

Exhale forcefully and cough rapidly

47). On admission the client is septic due do a ruptured appendix. The vital signs shows that the
pt has a 39.8 C temp, WBC 18,000, and bp of 68/4?. (there will be more values but I don’t
remember them) What class of medication is needed?

• Vasoconstrictor
48). There will be list of lab values that include a normal sodium level, a slightly elevated WBC,
another value that I don’t remember but it was normal and a BNP of 800.

• BNP 800
lOMoAR cPSD| 30970899
lOMoAR cPSD| 30970899
 Critical Care Exit HESI FORM C
Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes
telemetry pattern shows second degree heart block with Ventricular rate of 50. Action Hold
scheduled dose and notify HCP of telemetry pattern

Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Increased
conduction time from the SA node to the AV junction

When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on
right side only. Action
Reposition the depth of the ET tube

Nurse called to a train derailment likely caused by terrorist bomb. Triage in order
Middle-aged man wandering around Woman sitting on ground with blanket Crying child held by
another passenger Mother and father just arrived on scene

Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35.
Which needs immediate communication to HCP
Drowsiness and diff in arousing

Assess a 78 year old with L sided HF. Symptoms Dyspnea,

cough, fatigue

Caring for a burn patient with serum potassium of 4. Question which medication Potassium

Patient admitted with deep 2nd degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after
burn so nurse expects Decreased cardiac output

Patient bedridden for 2 wks with following lab values: pH 7.37, PO2 90, PCO2 40, HCO3 25,
hypoalbuminemia and hypocalcemia. Priority action Turn patient side to side q2h

Which age group should nurse assess first

40 year old with sickle cell crisis

There has been a major disaster. Triage nurse should give which patient priority Cut
over eye

Move which patient to medical surgical unit

Patient with ABNL liver levels

One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do
Take patient to ICU and arrange for respiratory patient to stay in PACU
Carotid picture Point to neck

Someone with wound vac how to make sure it is effective

Check seal to make sure no leaks
Magnesium antidote
Calcium gluconate

Patient having trouble swallowing when wife gives drink of water

Assess gag reflex OR may have been thickening answer-there were two alike

Chest tube becomes disconnected

Get new saline bottle to stick end into until reconnect tube

Patient in ventricular fibrillation

Defib shock once

Know calcium levels….there was a question with calcium 5.0 and the answer was patient
with hyperthyroidism taking inderal (propanalol)

Chest tube volume 125

Mark container between 100 and 150

Heart sounds audio

S1S2

Patient on benzos
Answer is not narcan

???
Abdominal rigidity

4 patients-which one more concern Low

Hgb level

4 patients with conditions of concern-priority

Make sure patient has units of blood available

Patient on Heparin going for surgery in a.m.,-priority Assess

patient for bleeds

Patient with fever of 101-best nursing Dx r/t

temperature elevation

Listening and hearing silence, then kortokoff sound what to do follow

through by checking BP
Patient with pancreatitis and elevated liver function-what expect of patient patient
drinks alcohol daily or lots/wk (alcohol related answer for sure) Patient with
dark, tarry stool
Sign of GI bleed, pick NSAIDS

Patient receiving Morphine in PCA pump Make

sure the lock is on the machine

Vasopressin
Vasoconstrictor

Patient comes in with Hx of MRSA put

in isolation, get swabs

Patient with thick secretions increase

fluids

Chronic renal failure-S/S

Patient would get a black tag during a disaster if he/she exhibited which S/S

Know your shocks S/S (hypovolemic, cardiogenic, etc-1 Q for each)

2 RNs must check blood products together before administration

Glasgow Coma Scale

<8 = coma

Myasthenia crisis vs. cholinergic crisis

Myasthenia-weakness with change in vitals (give more med)
Cholinergic crisis-weakness with no change in vitals (reduce med)

Diabetic ketoacidosis
Fruity breath

Hold Digoxin for HR <60

Stroke
Tongue points toward side of lesion (paralysis), uvula deviates away from the side of the lesion
(paralysis)

Pulmonary air embolus prevention

Trendelenburg (HOB down) and on left side to trap air in the right side of the heart

Head trauma and seizures

Maintain airway is primary concern

Hypoventilation
Acidosis (too much CO2)
Hyperventilation
Alkalosis (too little CO2)
Cardiac enzymes that you need to know how often to assess after initial CVA
Troponin (1 hour), CKMB (2-4 hrs), Myoglobin (1-4 hrs), LDH1 (12-24 hrs)

MI treatment
Morphine, oxygen, nitro, ASA (NO digoxin, betablockers or atropine for these patients)

Ventilators
Make sure the alarms are on (Check every 4 hours minimum), when suctioning give 100% O2 before
and after and make no more than 3 passes-no longer than 15 seconds

Have to put in order of consideration to be delivered

Nasal cannula, simple face mask, nonrebreather mask, partial rebreather mask, venturi mask

Early signs of cerebral hypoxia

Restlessness and irritability

Necessary for Blood Product infusions

18-19 gauge needle with filter tubing NS only run with blood within 30 minutes of hanging Check
vitals before infusing, at 15 minutes, 30 minutes, then every hour, and directly after

Checking blood before infusing

2 RNs Check order (expiration date, clots, color, air bubbles, leaks) patient, product, previous
transfusion Hx Premedicate with Benadryl for previous rxn

What does the PR interval represent

Time required for the impulse to travel from atria through the AV node

Isotonic solutions
D5W NS Lactated ringers

Tracheostomy
Keep Kelly clamp and obturator at the bedside

To assess CVA for hemorrhagic or ischemic CT

scan first

Heart conditions related to thrombus formation Afib

and A-flutter

Aphasia, agraphia, slow, cautious, anxious, memory ok Left

hemisphere lesion
Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant
smile, loss of tonal hearing Right hemisphere lesion Most important indicator of increased
ICP
Change in LOC

Spinal shock
Complete loss of all reflexes

If the U wave is most prominent what condition hypokalemia

Burns
First degree- epidermis {superficial} Second degree- epidermis and dermis {deep partial} Third degree-
epidermis, dermis, and subQ {full thickness}

Pic of patient and description of burns, need to decide what % burned

[Rule of 9s- head and neck=9%, UE=9% each, LE=18% each, front trunk=18%, back trunk=18%]

5 Ps of neurovascular status (important with fractures) Pain,

pallor, pulse, paresthesia, paralysis

S/S of shock
Increased pulse and decreased BP

S/S of IICP
Decreased pulse and increased BP with changes in LOC

Suspected Post op bleeding if assess

Frequent swallowing, vomiting blood, clearing of throat

Primary medications given in ED for respiratory distress

Bronchodilators [Sus-phrine (Epinephrine HCI) and Theophylline (Theo-dur)]

ABG normals for the following: pH, pCO2, HCO3 pH:

7.35-7.45, pCO2: 34-45 mmHg, HCO3: 22-26 mEq/L

Calculation of the heart rate using an EKG rhythm strip count the number of R-R
intervals in the 30 large squares and multiply by 10

Intracranial hypertension from a traumatic brain injury is admitted to the trauma unit Elevated
head of bed

CPR-Arrange in other of priority

Establish unresponsiveness Call for help Assess patent airway Assess pt carotid pulses

Endometrial carcinoma receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal
applicator
Wear a dosimeter film badge when in the client’s room
65-year-old female arrives in the ER with shortness of breath and chest pain, nurse accidentally
administers 10 mg of morphine sulfate instead of 4 mg as prescribed. Later, the client's respiratory rate is
10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided The client
would not be able to prove malpractice in court

Deep vein thrombosis on heparin protocol based on a tPTT of 65 to 95 seconds. The current PTT result
is 35 seconds
Increase the rate of the heparin infusion

Calculate the rate of this rhythm strip

(It should be 90-100 depending on which set of 6 squares you use)

A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol)

Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine (Mucomyst)

For increase magnesium level

Give calcium gluconate

Patient admitted with a Dx of diabetic ketoacidosis (DKA) with scant urinary output, K+2.5 mEq/l, pH of
7.26, T 98ºF, HR 128 bpm, RR 36, and BP 90/52 Pottasium IV at 20 mEq/250 ml over 1 hour

Irregular respiratory rate with periods of apnea lasting 10 to 15 seconds Apply

supplemental O2

The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is
indicated at 85%
Administer oxygen by face mask

Doing CPR on intubated client with palpable pulse during 2-min cycle of chest compressions, absent
breath sounds over left lung prepare for the endotracheal tube to be repositioned

Unresponsive client who ingested an unknown number of meperidine (DEMOROL) 50mg tablets.
Naloxone (NARCAN) 0.4mg IV is administered, and the client is now responding to verbal stimuli. Which
finding in the next hour requires immediate action by the nurse Difficulty in arousing

Patient in the MICU. What problem is a client probably experiencing who has an easily obliterated radial
pulse and below-normal pressures, (BP), (CVP), (PAP), and pulmonary under pressure Hypovolemic
shock

PRI interval depolarization and repolarization

Which is the highest for carcinogenic shock

traumatic amputation from the groin down (there one of the choice a pt w/ gunshot wound to the chest
and abdomen) *HESI HINT: if Cardiogenic shock exits in the presence of pulmonary edema (ex. from
pump failure), position pt to reduce venous return (high fowler’s w/ legs down) in order to reduce further
venous return to the left ventricle
Patient with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties
are secured to the side rail using a quick-release tie Reposition the restraints ties, securing them to the bed
frame

Nursing home patient admitted with urinary sepsis and has a single-lumen, peripherally-inserted central
catheter (PICC). Four medications are prescribed for 9:00 a.m.and the nurse is running behind schedule
(Zosyn) over 30 minutes q8 hours first

During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of
sustaining an epidural bleed
“Was your husband knocked out by the blow”

CPR for a pregnant lady

Heimlich w/ chest compression
*HESI HINT: At 20wks gestation & beyond, the gravid uterus should be shifted to the left by placing the
women in a 15-30 degree angled, left lateral position or by using a wedge under her right side to tilt her to
her left

Patient has received 250 ml of 0.9% normal saline through the IV line in the last hour and is now
tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. Decrease the saline to
keep-open rate

In EKG reading which complex represents depolarization of the ventricles QRS complex

The risk for metabolic shock syndrome

Toxic Shock Syndrome

23 year-old male brought to the ER by a group of fraternity brothers after a hazing event at the university.
Blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3
Initiate IV access using Lactated Ringer’s solution 1000ml with thiamine 100mg

The nurse in the emergency department is using the simple triage and rapid transport (START) system to
assess victims of a hurricane
A yellow disaster tag means critical injuries and require immediate intervention

Electrical burn pt put him in a cardiac telemetry

monitor

A pt on a trachea/endotrach with gurgling sound always

pick suctioning

Metabolic syndrome high cholesterol & high

BP (cardiac strip)
IV Line
Flush line before and after compatible IV solution

Priority pt
Ruptured spleen life threatening
Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual) Pleaurvac,
know how to set vac at 850

39 to 48 Glucose
Notify healthcare provider of client’s status

Disseminated intravascular coagulation (DIC) best

test to diagnose, D-Dimer

Septic shock-best class of medicine to give are Anti

infectives

A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his
eye
Have the parent take the child for emergency help

Patient admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The
healthcare provider determines the client is in acute renal failure (ARF) Hourly neurological assessments

14-year-old male arrives at the ER in status epilepticus. He was diagnosed with a seizure disorder in
childhood
Acute withdrawal from anticonvulsant medication

Most important symptom the nurse should monitor the client for while assisting with the insertion of a
subclavian central venous catheter Shortness of breath

Patient with Hx of chronic atrial fibrillation

Be sure to take the prescribed daily aspirin

Most important for the nurse to use an IV pump and/or Buretrol when initiating IV therapy after which
surgical procedure Craniotomy

Acute renal failure with a serum potassium of 7.5mEq/L. based on this finding Administer
a retention enema of Kayexalate

A client admitted to the hospital is suspected of having meningitis

Lumbar puncture

infant admitted to the NICU is tachypneic, tachycardic, and has bounding brachial pulses Monitor
for congestive heart failure
Feedings for low albumin
Nepro, Ensure or TPN if pt is NPO

BNP 500, prescribed diuretic indicates

HF
Acute Pancreatitis withhold food
and fluid intake

Mechanical life support Know

equipment used

Pulmonary Edema
Fluid leaks out of the small blood vessels into the air sacs of the lungs

CVP via PA port

Cover the cap w/ tape and label the port as being obstructed (While flushing the proximal port triple
lumen central venous cath w/heparin lock meets resistance)

In EKG reading which wave represents depolarization of the atrium P

wave

Math IV mg/kg/minutedopamine

Allen's test test for occlusion of the radial or ulnar artery, in which one of these arteries is compressed
after blood has been forced out of the hand by clenching it into a fist; failure of the blood to diffuse
into the hand when opened indicates that the artery not compressed is occluded

Pacemaker-Failure to sense
Fails to sense patient’s own intrinsic rhythm and generates a pacer spike (when output is too low
resulting in failure to depolarize the ventricle results in Bradycardia **Use Atropine)

DIC most often seen in leukemia and in adenocarcinomas of the lung, pancreas, stomach, and prostate

Diabetes -acute confusion

Give 4 oz. apple juice

Priority-compartment syndrome
Surgery needed. Emergency! Fasciotomy may be necessary

Head injury
major desired outcome for rehabilitation after head injury is to maximize the patient's ability to return
to his or her highest level of functioning

Pulmonary embolism-S&S
Dyspnea, sudden onset Pleuritic chest pain Apprehension, restlessness Feeling of impending doom
Cough Hemoptysis Tachypnea Crackles Pleural friction rub Tachycardia S3 or S4 heart sound
Diaphoresis Fever, low-grade Petechiae over chest and axillae Decreased arterial oxygen saturation
(Sao2)

Subcutaneous emphysema is felt as a crackling sensation beneath the fingertips

MODS (Multiple Organ Dysfunction Syndrome) after an Abdominal Gunshot wound
Apply pressure & keep flat Ventilator-ET to check placement listen to breath
sounds

Anaphylactic-bracelet patient should wear bracelet stating he is allergic

to certain medication

Shock –hemorrhagic give isotonic

0 .9% NS or LR

Heat stroke increase IV fluids to 200ml/hr, apply cool packs to persons

body

CPR-absent lung sounds

ventilate with two mouth to mouth breaths over 1 second and make the chest rise then palpate for
pulse, if no pulse do CPR

Myxedema coma S&S

hypothermia, bradycardia, hypotension, res. Acidosis. Happens when patient suddenly stops taking
thyroid med. Give thyroid replacement meds, Airway must be kept open

Burn airway, administer LR, premedicate with sulfamylon

CVA – Anosognosia lack of awareness or a denial of a neurological

defect paralysis

Patient in cardiac arrest and monitor shows pulseless VT

Defibrillation with 200 to 360 joules

Determine the following acid-base disorders pH

7.50, pCO2 30, HCO3 26 = respiratory alkalosis pH
7.30, pCO2 42, HCO3 20 = metabolic acidosis pH
7.48, pCO2 42, HCO3 32 = metabolic alkalosis pH
7.29, pCO2 55, HCO3 26 = respiratory acidosis
Identify the waveforms found in a normal EKG
P wave, QRS complex, T wave, ST segment, PR interval