CRITICAL CARE HESI FINAL EXAM QUESTION AND
CORRECT DETAILED ANSWER REAL EXAM 2024-2025
1.pt. long history of smoking; sob; ABG pH7.25, PCO2 50, HCO3 24 respiratory acidosis (if CO2 is high it will always be resp. acidosis) 2."heart is pounding outside of her chest" client is in SVT; intervention coach client in relaxation and deep breathing 3.insulin protocol; pt. insulin is infused at 5 units/hr and her current glucose reading is 165. what to do?increase drip by 1 unit/hr 4.calculate; 1,500,000 IU in 500 mL of 0.9% NS 33 5.DKA math question 1000 mL NS with 30 mEq of sodium 6.older client comes in with CAP and SpO2 89%. what is priority intervention?assist client with turning, coughing, and deep breathing 7.pt. received ETT 7 days ago and is currently on 50% O2. 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 bring her into ED; not feeling well. SIADH. what to do?initiate fall precautions (SIADH causes seizures) 9.UAP assisting nurse in situation where pt is having SVT and nurse has to prepare for cardioversion.what task for UAP bring resuscitation cart to the bedside 10pt has 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 surgery is anxious with SOB; intervention position client on the left side 1 / 3
12pt. receiving dopamine. monitor for what monitor urinary output 13during insertion of swan gans, what should nurse do monitor for dysrhythmias 14which vital signs are contraindicative of ICP?PaCO2 of 55 (normal PaCO2 should be between 35-45; when increased it will cause more ICP) SIADH with normal lab values associated with this hyperkalemia and hyponatremia 15pt. glasgow coma scale of 14. what should the nurse do document the findings 16when caring for a client on a ventilator which finding shows the airway is open? bilateral breath sounds can be auscultated 17pt. is in the ICU after a colon resection. vitals are HR 135, temp 103, BP 88/65, urine output 10 mL/hr.intervention?give a 500 mL IV bolus challenge (another question similar with low BP and same answer) 18client with syncopal episodes due to 3rd degree block. receives transcutaneous pacemaker; several fails increase the sensitivity 19which of these drugs are the strongest for most effective vasodilators lidocaine 20.mcg to mg; 4mcg/kg and client weighs 165 lbs 3.5 mL/hr 21.female falls down a flight of stairs and is having trouble walking and bearing weight. prescription for hydrocodone for pain and an xray. intervention have the client take a urine pregnancy test 22.pt. with chest tube has the tube dislodged from pleural space; intervention place an occlusive dressing with take on 3 sides 23.postop client admitted to ED with intra-arterial cannula; heparin infusing at 2 units per mL. what finding indicates the heparin has achieved therapeutic use the IA remain patent 24.pt. arrives to the ED with pain. description should prompt nurse to suspect an MI produces chest heaviness with left arm pain 25.what equipment should always be made available at the bedside for a pt. with a chest tube occlusive dressing 2 / 3
26.things should be done if an ET tube is in place chest xray chest rises and falls bilaterally auscultate breath sounds 27.pt. comes in with severe hypotension. what medication should you expect a prescription for?amiodaron 28.female has been asystole for 20 minutes and there has been no change in the client's condition; intubated; what should the nurse do talk to the family members in a private area about desire to continue life support 29..47 year old female that comes in and thinks they have indigestion due to vigorous workout. which problem has highest priority? decreased cardiac output EKG strip prepare the client for pericardiocentesis 30.treated for MI that occurred less than 6 hrs ago; MD suspects 100% occlusion; what does the EKG show sinus bradycardia Q waves and ST elevation QRS lengthening 31.list of vitals and patient will come in 2 hours after being in pain; what does nurse suspect the patient to have acute pancreatitis 32.client has pneumothorax and has chest tube with NO fluctuation in the water seal assess lung sounds 33.male falls 20 feet and the nurse observes it; client has no pulse begin CPR 120 per 1 min 34.older woman pt. that feels very weak and is having a hard time breathing; leaning over while the nurse is doing assessment and cant keep head up; intervention keep the client in high fowlers 35.client on a ventilator; intervention done so that the pt. doesn't develop VAP oral hygiene 36.pt getting an ET tube; MD has sedated the pt and the pt has soft restraints; intervention test to see if the pt is aggressive once the sedation has weened down 37.trying to place an IV in pt that is confused and anxious; intervention notify MD for a restraint so that the pt.can get the IV they need 38.what do you do prior to drawing from an arterial line allens test
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