Critical Care Exit HESI- Questions and Answers
Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes telemetry
... [Show More] 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 [Show Less]