HESI RN CRITICAL CARE ACTUAL EXAM V1 COMPLETE 500

HESI RN CRITICAL CARE ACTUAL EXAM V1 COMPLETE 500

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Term 1 of 124

Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?

• Encourage the client to breathe slower.
• Notify the healthcare provider of the crisis blood gas values.
• Encourage the use of an incentive spirometer.
• Increase the oxygen flow to 6 liters/minute.

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• Young adult female presents with periorbital ecchymosis on right side, 3 cm

laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive.Rationale: Proper documentation of abuse as reported by the victim is crucial, and (D) is specific and gives an accurate depiction of the events without documentation of judgmental inferences.(A, B, and

• lac

C k .s E p n e c c o if u ic r i a ty ge an th d e im us p e o o rt f a a n n t d in e c t e ai n ls tiv r e la s t p e ir d o t m o e t t h e e r.event

RATIONALE:

The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation (PaC02 > 45). The client needs to be encouraged in activities that increase the depth of breathing (e. g., use of the incentive spirometer) (B). (A) will only increase an already adequate Pa02. These are not crisis blood gas findings (C). (D) will only worsen the hypoventilation

• Obtain the permission of the custodial parent for the surgery.

RATIONALE:

The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does not need to co- sign this form (D).

• Implements health programs for construction workers.

Rationale: Implementing health programs for construction workers (B) is an example of a competent performance criterion in management, which includes monitoring of the quality and effectiveness of vendor services. (A) is an example of an expert performance criterion for case management. (C and D) are examples of a proficient performance criteria for management.

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Term 2 of 124

The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?

• Wear the brace over a T-shirt 23 hours per day.
• Dress with the brace over regular clothing.
• Shower with the brace directly against the skin.
• Remove the brace just before going to bed.

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• Drinks 240 mL of fluid five times during the shift

RATIONALE:

The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake.

• Wear the brace over a T-shirt 23 hours per day.

RATIONALE:

Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace. 3 / 4

• History of inflammatory bowel disorders.

RATIONALE:

Enemas should be avoided or administered with extreme caution to clients with inflammatory bowel disorders, so obtaining this historical information has the highest priority (A). (B and C) also provide valuable information, but are not of the same priority as (A). (D) is not necessary prior to enema administration.

Assign the client to a negative air-flow room

RATIONALE:

Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment.

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Term 3 of 124

An 80-year-old client is given morphine sulphate for postoperative pain.Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?

• Antacids.
• Tricyclic antidepressants.
• Nonsteroidal anti-inflammatory agents.
• Insulin.
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