HESI 4 REVIEW - CRITICAL CARE - MCA 3 ANSWERED CORRECTLY WITH RATIONALES 2022/2023

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HESI 4 REVIEW - CRITICAL CARE - MCA 3 Which color-tagged clients usually make up the greatest number in most large-scale multi-casualty situations, based on the disaster triage tag system? Red Bl... ack Green Yellow Which color tag will be given by the triage nurse to a client assigned to class IV during a mass casualty situation? Red Black Green Yellow In a mass casualty situation, which is the facility-level organizational model for disaster management used by the hospital or long-term care facility? Emergency operations center (EOC) Hospital Incident Command System (HICS) National Incident Management System (NIMS) Federal Emergency Management Agency (FEMA) Which area of assessment is included in the Glasgow Coma Scale? Breathing patterns Deep tendon reflexes Eye accommodation to light Response to verbal commands A group of bomb blast victims needs to be transported to the hospital immediately. Which staff members of an emergency unit are most appropriate to handle this situation? Triage officer Medical command physician Prehospital care providers Emergency medicine physician Which parameters would the nurse consider for proper rapid baseline assessment using a disability mnemonic (AVPU) in a client with drug abuse? Select all that apply. One, some, or all responses may be correct. Level of anxiety Reaction to pain Response to voice Body temperature Evidence of assault The postanesthesia care unit nurse providing care for a client who had a craniotomy for a meningioma would monitor for which specific clinical manifestation in this client? Dehydration Blurred vision Wound infection Narrowing pulse pressure Which action of the emergency department nurse caring for a group of clients injured in a community disaster would need correction? Triaging the victims Supervising volunteers Providing on-site first aid Removing people from danger A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action? Administering oxygen Elevating the head of the bed Drawing blood for a hematocrit level Giving an intramuscular analgesic Which personnel are responsible for identifying the need for and calling in specialty trained providers in emergencies? Triage officer Public information officer Medical command physician Hospital incident commander Which is an example of an internal disaster in a hospital? A hurricane Oil spill from a marine oil tanker Loss of communications capabilities Malfunction of a nuclear reactor with radiation exposure Which is the minimum length of time victims of a large scale near- drowning incident brought to the emergency department would be kept under observation in the hospital? 12 hours 18 hours 23 hours 48 hours As a surface rewarming measure for a client who is hypothermic, which is the highest temperature up to which the fluid can be heated for peritoneal lavage? 98.6°F (37°C) 111.2°F (44°C) 113°F (45°C) 120.2°F (49°C) A client is bitten by a snake while out hiking with the nurse. Which action would the nurse take first? Take digital photographs of the snake. Call for immediate emergency assistance. Remove jewelry and any constricting clothing. Move the client to a safe area away from the snake. Which intervention is the highest priority prehospital intervention for a client bitten by a snake? Sucking the venom out of the bitten area Offering alcohol to the client Applying ice to the affected area Immobilizing the affected extremity using a splint Which biological agent of terrorism is treated with antitoxin? Plague Anthrax Botulism Smallpox Which is the function of the medical command physician according to the Emergency Preparedness and Response Plan? Deciding the number, acuity, and resource needs of clients Serving as a liaison between the health care facility and the media Assuming overall leadership for implementing the emergency plan Evaluating each client rapidly to determine priorities for treatment Which type of emergency assessment is being performed when the nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident? Disability Breathing Focused adjuncts Giving comfort measures A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? Dull sound on percussion Vocal fremitus on palpation Rales with rhonchi on auscultation Absence of breath sounds on auscultation Which emergency medical service agency offers service such as first aid stations and special-need shelters during a disaster or pandemic disease outbreak? Medical Reserve Corps (MRC) National Disaster Medical System (NDMS) Disaster Medical Assistance Team (DMAT) Federal Emergency Management Agency (FEMA) - Which color tag is assigned the lowest priority for care in a mass casualty event? Red Black Green Yellow Which action would the nurse perform as the highest priority for a client with trauma in the emergency unit? Applying dry dressing Evaluating chest expansion Providing adequate oxygen (O 2) supply. Applying direct pressure on a bleeding site Which problem is indicated by a positive contraction stress test (CST)? Preeclampsia Placenta previa Fetal prematurity Uteroplacental insufficiency In a mass casualty situation, which health care professional can direct departments such as physical therapy or a surgical clinic to cancel their usual operations to convert the space into a minor treatment area? Triage officer Community relations officer Medical command physician Hospital incident commander Which type of emergency assessment is the nurse performing when the nurse reassesses level of consciousness and mental status in a client who survived a fire? Airway Disability Breathing Full set of vital signs Which conditions of the clients who are admitted with injuries due to a bus accident are prioritized under the emergent classification? Select all that apply. One, some, or all responses may be correct. Shock Contusion Open fracture Airway obstruction High cervical spinal cord injury Which activity is performed first when a client is bitten by a brown recluse spider? Removing the necrotic tissue Elevating the affected extremity Allowing complete rest to the client Applying cold compresses over the site Which clinical indicators would the nurse consider evidence of increasing intracranial pressure? Select all that apply. One, some, or all responses may be correct. Vomiting Irritability Hypotension Increased respirations Decreased level of consciousness Which statement about the injuries caused by explosive devices used as agents of terrorism would the nurse know to be true? Penetrating injuries primarily damage the middle ear. Blast injuries primarily damage the gastrointestinal (GI) tract. Penetrating injuries are caused by the supersonic over pressurization shock wave. Blast injuries are caused by explosions in confined spaces causing structural collapse. What does the nurse consider to be the priority nursing intervention for a client on diuretic therapy who has developed metabolic alkalosis? Preventing falls Monitoring electrolytes Administering antiemetics Adjusting the diuretic therapy A client develops bacterial meningitis. Which action is the priority nursing care? Monitoring for signs of intracranial pressure Adding pads to the side of the bed Administering prescribed antibiotics Administering glucocorticoids A client is burned on the anterior part of both legs, from the knees to the feet. Which percentage of total body surface area (TBSA) burned would the nurse document in the client's hospital record, using the rule of nines? 9% 18% 27% 36% Which action would the nurse initiate first to ensure the physical safety of a client with severe preeclampsia? Institute seizure precautions. Decrease environmental stimuli. Administer the prescribed sedatives. Strictly monitor her intake and output Which nursing intervention is the most effective in preventing a seizure in a client with severe preeclampsia? Providing a plastic airway Controlling external stimuli Having emergency equipment available Keeping calcium gluconate at the bedside . Which scenarios mentioned by the registered nurse is considered secondary acute care? Prepares a client who has suffered from repeated cerebral attacks for a CT scan Performing physical examinations and monitoring fetal movement in a pregnant woman Teaching family members about the importance of being vaccinated and the risks associated with a lack of vaccinations Checking a client's heart rate and blood pressure before administering entacapone and isoproterenol concurrently Which type of damage is most likely caused by a crush injury to victims of a terrorist attack involving explosive devices? Middle ear injury Blunt trauma to the head Shrapnel injury in the abdomen Damaged lungs due to shock wave Which finding will the nurse expect when analyzing the cardiac rhythm for a client with first degree atrioventricular (AV) block? Every P wave is conducted to the ventricles. Some P waves are conducted to the ventricles. There are no P waves visible on the rhythm strip. None of the P waves are conducted to the ventricles. A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. Which is the priority intervention? Teaching coughing and deep-breathing techniques Cleansing the surgical site and administering an enema Providing a sterile gown and inserting an indwelling catheter Ensuring that an informed consent is obtained and that the client is assessed for medication allergies The nurse is caring for a client with severe burns 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? Milk Tea Orange juice Tomato juice Where will the nurse place the V 1 lead when obtaining a 12-lead electrocardiogram? Fifth intercostal space, left midaxillary line Second intercostal space, left sternal border Fourth intercostal space, right sternal border Fifth intercostal space, left midclavicular line The parents of a preterm newborn visit the neonatal intensive care unit (NICU) for the first time. They are obviously overwhelmed by the amount of equipment and the tininess of their baby. Which is the nurse's most appropriate response to their reaction? Placing the baby in the mother's lap Showing the parents how to touch the baby Explaining the purpose of the equipment being used Discouraging the parents from staying too long on this first visit Which intervention would the nurse anticipate will be provided for the newborn of a mother with a long history of diabetes? Fast-acting insulin Special high-risk care Routine newborn care Limited glucose intake Applying the emergency severity index (ESI) criteria, which client condition is considered least severe? Cardiac arrest Abdominal pain Multiple trauma Closed extremity trauma Which staff members will be the first to manage the care of victims from an accident at the nuclear power plant? Emergency medicine health care provider Emergency medical technicians Paramedics Prehospital care providers Which biological agents of terrorism can be treated effectively with antibiotics? Select all that apply. One, some, or all responses may be correct. Plague Anthrax Botulism Smallpox Tularemia Which of these clients in the emergency department would the nurse see first? A client with a head injury A client with a fractured femur A client with ventricular fibrillation A client with a penetrating abdominal wound The nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. About which type of graft will the nurse educate the client? Isograft Allograft Homograft Heterograft The client with which color tag would be treated first, according to the disaster triage tagging system? Red Black Green Yellow Which problem is suggested when a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity followed by fundal tenderness and a small amount of dark-red bleeding? True labor Placenta previa Partial abruptio placentae Abdominal muscular injury A client has a diagnosis of partial-thickness burns. While planning care, the nurse recalls that the client's burn is different than full-thickness burns. Which information did the nurse recall? Partial-thickness burns require grafting before they can heal. Partial-thickness burns are often painful, reddened, and have blisters. Partial-thickness burns cause destruction of both the epidermis and dermis. Partial-thickness burns often take months of extensive treatment before healing. Initially after a stroke, the client's pupils are equal and reactive to light. Four hours later, the nurse identifies that one pupil reacts more slowly than the other and the client's systolic blood pressure is increasing. For which condition would the nurse prepare to intervene? Spinal shock Brain herniation Hypovolemic shock Increased intracranial pressure Which would the registered nurse say is the priority action of first responders after a community disaster? Providing on-site first aid Providing emergency care Removing the victims from danger Categorizing victims using triage system Which equipment will the nurse prepare for a client whose burn wounds are scheduled to be debrided mechanically? Enzymatic agents Scissors and forceps Autolytic semiocclusive dressing Continuous passive-motion device Which client condition would require the highest priority for treatment among four clients admitted at the same time under mass casualty conditions? A - MASSIVE HEAD TRAUMA B - OPEN FRACTURE WITH DISTAL PULSE C - SHOCK D- STRAINS AND CONTUSIONS When the triage nurse assigns a green tag to a client during triage after a mass casualty event, which statement is true about the client's injuries? The client is expected and allowed to die. The client has an immediate threat to life. The client has major injuries that require treatment. The client has minor injuries that do not require immediate treatment. The client with which tag color requires immediate treatment in the emergency department according to disaster triage tag system? A - YELLOW B - RED C - GREEN D - BLACK Which emergency medical service agency offers service for a group of clients admitted to the emergency unit with mass fatalities? Medical Reserve Corps (MRC) Hospital Incident Command System (HICS) International Medical-Surgical Response Teams (IMSRT) Disaster Mortuary Operational Response Teams (DMORT) Which statement would the nurse know to be true regarding the characteristics of sarin? Sarin causes skin burns and blisters. Sarin can cause death within minutes of exposure. A garlic-like odor and brown color are characteristics of sarin. A single dose of pralidoxime chloride (2-PAM chloride) reverses the effects of long-term sarin exposure. The client with which treatment needs belongs to class I according to the disaster triage tag system? Can wait a short time for treatment Is dead or expected to die Needs emergency treatment Has no urgent need for treatment Which conditions are given a green tag according to triage disaster tag system? Select all that apply. One, some, or all responses may be correct. Strains Abrasions Open fractures Airway obstruction High cervical spinal cord injury Which assessment finding alerts the nurse to increasing intracranial pressure? Hypervigilance Constricted pupils Increased heart rate Widening pulse pressure Which role does the "doorkeeper" enact in a critical incident stress debriefing (CISD) team? Helping dispel any feelings of blame or guilt in the participants Encouraging group discussion through asking a series of questions Educating participants about self-care concepts and coping strategies to use immediately Talking with anyone who leaves the session early in an effort to have him or her return or accept follow-up Which nursing intervention has the highest priority for a client who was in a motor bike accident and has a severe neck injury? Assessing for crepitus Assessing for bleeding Maintaining a patent airway Performing neurological assessment Which goal is the nurse trying to achieve by reinforcing to the client that it is important to seek treatment for primary open-angle glaucoma (POAG)? Prevent cataracts Prevent blindness Prevent retinal detachment Prevent blurred distance vision Which triage class client would the nurse plan to treat first according to the disaster triage tag system? Class I Class II Class III Class IV Which client would be treated first? Client A - AIRWAY OBSTRUCTION Client B - extensive full- thickness burns Client C - open fractures Client D - closed fracture and abrasions For which complication would the nurse closely monitor a client with a diagnosis of abruptio placentae? Cerebral hemorrhage Pulmonary edema Impending seizures Hypovolemic shock Which component of sea water is known to be responsible for making sea water hypertonic compared with body fluids? Salt Mud Algae Chlorine Which Glasgow Coma Scale score indicates that the client is in a coma? 6 9 12 15 A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which dietary adjustment would the nurse recommend? Increase low-sodium milk intake. Provide high-protein drinks. Increase foods that are low in potassium. Provide 10% more calories in the form of fats. Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? Hazy Yellow Brown Colorless A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. Which percentage of total body surface area (TBSA) would the nurse calculate? 20 25 30 36 Which health care professional serves as the liaison between hospital administration and the media to release only appropriate and accurate information in the event of a mass casualty event or disaster? Triage officer Community relations officer Medical command physician Hospital incident commander Which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm? Obstructive Neurogenic Cardiogenic Hypovolemic Which client would be triaged under emergency severity index (ESI)-1 based on threat to life and stability of vital functions? A - CHEST PAIN FROM ISCHEMIA B - CARDIAC ARREST C - SIMPLE LACERATION D - HIP FRACTURE A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. Which priority action would the nurse instruct the client to take? "Stay in bed for at least 3 days." "Keep the legs elevated while sitting."" Apply a warm compress to the affected calf twice a day." "Go to the emergency department immediately." Which client would be triaged first based on condition? A - SEVERE RESP DISTRESS B - CHEST PAIN FROM TRAUMA C - HIP FRACTURE IN OLDER PX D - CYSTITIS Which information would the nurse include when explaining the purpose of a thallium scan to the client who has a history of chest pain? It monitors action of the heart valves. It assesses myocardial ischemia and perfusion. It visualizes ventricular systole and diastole. It identifies the adequacy of the conduction system. Which information would the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method? Aseptic techniques are required. Plants, but not flowers, are allowed. Equipment will be shared with others. Dressings will be changed every 3 days. Which intervention is the highest priority nursing action for a client with a scorpion bite? Assessing the client's vital signs Applying an ice pack to the sting site Contacting the poison control center Covering the client with cooling blanket A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding would the nurse expect when performing the admission assessment? Weak, rapid pulse Decreased blood pressure Radiating anterior chest pain Crackles at bases of the lungs A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. Which intervention, upon delivery of the infant, is a priority? Stimulating crying Administering oxygen Placing the newborn on the mother's chest Providing for suctioning of the oropharynx as the head emerges When helping a triage officer evaluate the victims of a large-scale disaster, which client would the nurse anticipate will be given a black tag? A client with a contusion A client with airway obstruction A client with open fractures and a distal pulse A client with extensive full-thickness body burns Which action would the nurse take before developing the teaching plan for a client who has had a myocardial infarction? Identify the learning needs of the client. Determine the nursing goals for the client. Explore the use of group teaching for the client. Evaluate the community resources available to the client. Which condition is triaged as urgent among these client conditions? A - DISPLACED OR MULTIPLE FRACTURES B - SKIN RASH C - STRAINS AND SPRAINS D - SIMPLE FRACTURE A client is admitted to the post-anesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what would the nurse do? Raise the drainage system to bed level and check its patency Clamp the tube when moving the client from the bed to a chair Mark the time and fluid level on the side of the drainage chamber Secure the chest catheter to the wound dressing with a sterile safety pin Which condition will be given the highest priority for a client admitted in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia? Hypoglycemia Chest wall trauma Airway obstruction External hemorrhage Which is the most appropriate nursing intervention for a client admitted to the high-risk prenatal unit at 35 weeks' gestation with a diagnosis of complete placenta previa? Applying a pad to the perineal area Having oxygen available at the bedside Allowing bathroom privileges with assistanceE ducating the client regarding the intensive care nursery A client receives an autograft for a severe burn and is taught how to change the dressing. One week after receiving the graft, the client identifies that the edges of the graft are curling up and asks the nurse about it. Which is the best response by the nurse? "May I take a look at it?" "It's time for another graft." "Is there any sign of redness?" "It is supposed to curl up at the edges." A person on the beach sustains a deep partial-thickness sunburn. Which first-aid measure would the nurse recommend before the client seeks health care? Cool, moist towels Dry, sterile dressings Analgesic sunburn spray Vitamin A and D ointment The client admitted to the emergency department after an earthquake in the city with which level of resource intensity would the nurse triage into emergency severity index level 1 (ESI-1)? A - High resource intensity B - HIGH RESOURCE INTENSITY, STAFF AT BEDSIDE CONT C - receiving medium to high resource intensity D - low resource intensity involving one simple diagnostic Which statement best describes the condition of a client who the triage nurse assigned a red tag? The client is expected and allowed to die. The client has an immediate threat to life. The client has major injuries that require treatment. The client has minor injuries that do not require immediate treatment. The nurse is planning to triage clients after a disaster. Which client does the nurse categorize into the green-tagged category? A - AIRWAY OBTS B - OPEN FRACT C - MASSIVE HEAD TRAUMA D - BRUISES LACERATIONS ON SKIN Which inference would the nurse draw when crackles are heard while auscultating the lungs of a client admitted with severe preeclampsia? Seizure activity is imminent. Pulmonary edema may have developed. Diaphragmatic function is being impaired by the enlarged uterus. Bronchial constriction was precipitated by the stress of pregnancy. Which client requires lowest priority according to the Glasgow Coma Scale? EYE - MOTOR - VERBAL A - 1, 2, 3 B - 2, 3, 3 C - 3, 5, 3 D - 4, 5, 5 A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare? A high-forceps birth An immediate cesarean birth Insertion of an internal fetal monitor Administration of an oxytocin infusion After experiencing acute coronary syndrome, a client who has begun an exercise program asks the nurse how to tell whether the exercise is helping. Which response would the nurse make? "Intermittent claudication will be reduced." "Your breathing will become regular and shallow." "Perspiration will be less when you run, and you'll use less energy." "You will be able to walk progressively longer distances before tiring." A client in the emergency department presents with signs and symptoms indicative of an opioid overdose. Which medication would the nurse anticipate administering? Naloxone Methadone Epinephrine Amphetamine Based on their conditions, which client would be triaged first according to the 3-tiered triage system? A - CHEST PAIN B - MULTIPLE FRACT C - RENAL COLIC D - STRAINS SPRAINS A client with which condition would the nurse treat first according to a three-tiered triage system? Respiratory distress Multiple soft tissue injuries New onset of respiratory tract infection Skin rash and a simple lower limb fracture HESI Patient Reviews with RN Case Studies and Practice Test - ______________________________________________________________________ The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two inches above and left of the victim's xiphoid process. Which vital organ(s) are at an increased risk of being in the direct path of injury? (Select all that apply.) Heart. Lungs. Stomach. Intestines. Diaphragm. A client reports to the nurse feeling achy and weak, being tired and coughing all the time, frequent headaches and experiencing night sweats. The client's assessment is significant for crackles scattered throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse prepare to do first? Metabolic panel with electrolytes. Complete blood count. Liver function test. Blood culture. According to the paramedic's report, the victim of a motor vehicle collision was sitting in the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic light when the vehicle was hit on the left side by another vehicle traveling at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L) side of thorax and body. The significant assessment findings include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is present in the (L) flank area and progresses towards the abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula.Which potential injuries should the triage nurse assess? (Select all that apply.) Flailed ribs. Fractured liver. Ruptured spleen. Cardiac tamponade. Tension pneumothorax. The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse interpret this blood gas? Respiratory acidosis. Respiratory alkalosis. Metabolic acidosis. Metabolic alkalosis. The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated. The ABG results are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the nurse interpret this blood gas? Fully compensated respiratory acidosis. Fully compensated respiratory alkalosis. Fully compensated metabolic acidosis. Fully compensated metabolic alkalosis. The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? Change in level of consciousness. Increase in urinary output. Onset of Kussmaul respirations. Decrease in serum potassium level. The nurse is caring for a client in the critical care unit who has a pituitary tumor and subsequent diabetes insipidus (DI). Which finding indicates the need to place the client on seizure precautions? Sodium 155 mEq/L or mmol/L. Arterial pH 7.42. Calcium 9.5 mEq/L (4.75 mmol/L) Potassium 4.9 mEq/L or mmol/L. A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription should the nurse implement first? Obtain serum sodium levels every 4 hours. Provide oral sodium chloride supplements. Monitor fluid restriction and document hourly intake and output. Initiate normal saline IV at 100 mL/hour. The nurse is caring for a client in the critical care unit who has type 2 diabetes mellitus and is admitted with hyperglycemic hyperosmolar syndrome (HHS). The health care provider prescribes an insulin drip of 0.1 unit/kg per hour based on a current blood glucose level of 670 mg/dL (35.3 mmol/L) . Which intervention should the nurse perform during this infusion? Obtain blood glucose levels hourly. Give potassium chloride 40 mEq per secondary infusion. Infuse Dextrose 5% with 0.45% NaCl (D 5 1/2 NS). Initiate a 2,000 calorie diabetic diet. The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process? Encourage the family to give the client permission to die. Revoke the "do not resuscitate" advanced directive. Send the family to an area to seek spiritual comfort. Give the client pain medication during the end of life hours. The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the nurse? Increased pulmonary secretions. Intercostal muscle retraction. Decreased breath sounds. Bronchovesicular breath sounds. A client who experienced an intracranial hemorrhage is receiving cistracurium to induce a pharmacological state of paralysis. Which intervention should the nurse implement during the therapeutic paralysis? Administer a sedating medication. Monitor the client for seizures. Titrate the drug dose to prevent addiction. Check the client's gag reflex every 2 hours A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted. Which finding should the nurse observe for during the immediate hours after insertion? Beck's triad. Burns around the site Hypothermia Cardiac arrhythmia. A client with a demand pacemaker has a telemetry tracing with a pacing spike but no corresponding QRS complex. The client's myocardium is illiciting a QRS after a delay of several seconds. Which telemetry interpretation should the nurse conclude? Loss of capture. Ventricular fibrillation. Capture from an ectopic focus. A normal finding with a demand pacer. A client who arrived in the emergency department is experiencing status epilepticus. Which medication should the nurse administer immediately? Lorazepam IV. Phenytoin PO. Morphine IV. Levetiracetim PO. A client who returns to the postoperative unit after a total thyroidectomy suddenly becomes short of breath and develops stridor. What action should the nurse implement first? Call the rapid response team for emergency assistance. Encourage the client to relax as respiratory effort eases. Document the findings and monitor the client hourly. Call respiratory therapy to provide cool mist oxygen per mask. A client with chronic kidney disease (CKD) is admitted for strict fluid restriction. Which assessment finding requires additional nursing action? Crackles in the lungs. Decreased serum creatinine level. Increased weakness. Increase in serum potassium. A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern? Kussmaul respirations. Cheyne stokes respirations. Apnea. Orthopnea. . A client in the intensive care unit receives a STAT prescription for mannitol IV for cerebral edema post closed head injury. Which action should the nurse implement when preparing to administer the medication? Use a filtered needle to draw up the medication and an in-line filter during infusion. Place atropine at bedside for use if the client has bradycardia during administration. Hyperventilate the client prior to administration to decrease intracranial pressure. Stop all sedation while mannitol is being administered per secondary infusion. The nurse reports findings to the healthcare provider for a client who is admitted to the intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report using the SBAR format, which statement best supports the nurse's reason for calling the healthcare provider? Prescription for an additional respiratory treatment. Admission today with difficulty breathing. History of COPD. Presence of expiratory wheezes in the lower lobes. The nurse is caring for a client who is receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). The ventilator is alarming continuously indicating high peak pressures for the client. Which pathologic changes in the client is causing the ventilator alarms? Decreased lung compliance. Increased respiratory rate. Low volume of expired air. High tidal volumes A client is trying to talk with an endotracheal tube in place for mechanical ventilation. Which method is most readily available for the nurse to provide the client for communication? Communication board or paper pencil to write messages. Hand gestures that explain what the client wants to say. Communication by interrupting ventilator for short periods of time. Touch screen figures or text to voice communication computers. The nurse is preparing to suction an intubated client's endotracheal tube (ETT). Which action should the nurse do first prior to suctioning the client's ETT? Instill sterile normal saline into the ETT. Hyperoxygenate with 100% FiO 2 for 30 seconds. Increase the respiratory rate settings on the ventilator. Adjust the suction apparatus to low intermittent setting. Which intervention should the nurse perform prior to the removal of an endotracheal tube from a client? Suction the endotracheal tube thoroughly. Pre-medicate the client with pain medication. Increase the FiO 2 for a minimum of 15 minutes. Provide positive pressure ventilation prior to extubation. A client who is critically ill requests to receive the Sacrament of the Anointing of the Sick. Which clergy member should the nurse contact? Rabbi. Priest. Sharma. Ayatollah. A client placed on hospice care is admitted for palliative radiation treatments to the neck. Which assessment should the nurse identify as a priority? Pain assessment. Respiratory assessment. Cardiovascular assessment. Integumentary assessment. A client diagnosed with heart failure has hemodynamic monitoring in place. Which actions should the nurse perform to obtain accurate readings from the hemodynamic monitor? (Select all that apply.) Measure the pressure readings in between the client's breaths. Place the transducer at the client's atria level and pulmonary artery level. Maintain a maximum pressure of 100 mmHg for the flush line continuously. Change out the intravenous solutions infusing via central lines every 12 hours. Calibrate the hemodynamic monitor by zeroing the transducer at the start of each shift. The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The ABG results are pH - 7.17; paCO2 - 70 mmHg; HCO3 - 30 mEq/liter. How should the nurse interpret this blood gas? Respiratory acidosis. Respiratory alkalosis. Metabolic acidosis. Metabolic alkalosis. The nurse is preparing a client with acute kidney injury (AKI) f or hemodialysis in the intensive care unit (ICU). Which assessment should the nurse obtain prior to beginning the procedure? Weight using the ICU bed scales. Arteriovenous (AV) fistula site. Capillary refill. Urine color and clarity. The nurse is caring for a client who is 4 days postoperative for abdominal surgery. The client reports acute onset of difficulty breathing. The nurse obtains the vital signs which include a heart rate of 120 beats/minute and respirations of 35 breaths/minute. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? D-dimer blood test. Coagulation time and platelet count. Echocardiogram. Mass spectrometry. A chest X-ray is prescribed for a client with possible adult respiratory distress syndrome (ARDS). Which radiographic finding represents the pathological processes of pulmonary edema and consolidation of the lungs as ARDS progresses ? White-out appearance. Infiltrates. Calcified cavities. Multiple nodules. As adult respiratory distress syndrome (ARDS) progresses, a "white-out" appearance on the chest X-ray indicates opacity of pulmonary edema and density of lung consolidation. Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to water seal. The client is using the incentive spirometer hourly while awake. Which assessment finding warrants intervention by the nurse? Serosanguineous fluid in collection container. Fluid fluctuation in tubing with respirations. Water seal level2 cm below the water seal fill line. Reportof chest tube insertion site tenderness. A client is admitted to the intensive care unit with urosepsis. Which findings should the nurse report to the healthcare who suspects the client is at risk systemic inflammatory response syndrome (SIRS)? Temperature 102 F (38.9 C), PaCO 2 28, and apical pulse 100 beats per minute. Temperature 101 F (38.3 C), PaCO 2 55, apical pulse 80 beats per minute. Temperature 98.7 F (37.1 C), white blood cell count 5.5 cells/mm 3, respiratory rate 20 breaths per minute. Temperature 100.2 F (37.9 C), white blood cell count 10.0 cells/mm 3, respiratory rate 18 breaths per minute. The nurse is caring for a client admitted to the intensive care unit with a traumatic brain injury from a motor vehicle collision. The client is experiencing increased intracranial pressure (ICP). The healthcare provider explains to the family that the client needs to go to surgery for decompressive craniectomy. Which information should the nurse explain to the client? An over-lying cranial bone flap is removed to allow swelling brain tissue to expand. The procedure uses a magnetic resonce imaging-guided laser ablation. An opening into the skull is made to remove damage tissue. A burr hole is drilled through the cranil bones to evacuate blood. - The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries sustained in a motor vehicle collision. The client has a Glasgow Coma Score of 6. Which intervention should the nurse prepare for the client? Intubation with mechanical ventilation. Nasogastric tube placement. Advanced cardiac life support. 12-lead electrocardiogram (ECG). The nurse is caring for a client admitted to the surgical intensive care unit (SICU) on the first postoperative day after a kidney transplantation. Which intervention should the nurse include in the plan of care to prevent hypovolemia? Give IV fluids on a 1:1 ratio from output. Administer loop diuretics. Increase sodium intake. Provide sports drinks for hydration. The health care provider has determined that a client has irreversible brain damage with subsequent brain death. Organ donation is discussed with the family. Which action should the nurse take prior to contacting the organ procurement organization (OPO)? Obtain informed consent. Disconnect the ventilator. Remove all jewelry. Contact the medical examiner. Two days after surgical repair of an aortic abdominal aneurysm (AAA), the cardiac monitor is displaying sinus bradycardia and blood pressure 82/40 mmHg. Nitroprusside is infusing at 10 mcg/kg/min and 0.9% sodium chloride at 100 mL/hr. Which intervention should the nurse implement first? Place the client's head flat and elevate the feet. Stop the nitroprusside infusion. Rapidly administer 1 liter intravenous fluids. Increase the 0.9% sodium chloride to 150 mL/hr. The nurse is analyzing an arterial blood gas of a client who is mechanically ventilated. The ABG results are pH - 7.37; paCO2 - 30 mmHg; HCO3 - 28mEq/liter. Which should the nurse recognize as a cause of these findings? Decreased respiratory rate causing respiratory acidosis. Decreased respiratory rate causing respiratory alkalosis. Diarrhea with a fully compensated metabolic acidosis. Nasogastric suction with a fully compensated metabolic alkalosis. - A client falls off a ladder approximately 15 feet high and is admitted to the ICU for observation due to a small intracranial bleed noted in the left occipital area of the brain as observed on the CT Scan done in the emergency department. The client has been stable for the past 12 hours. The client reports to the nurse a new onset of pain in the left shoulder. Which action should the nurse do next? Contact the healthcare provider. Perform an abdominal assessment. Observe the client's pupillary response. Examine the left shoulder's range of motion. The nurse is collecting a sample for arterial blood gases (ABGs) for a client with hypoxia due to cardiomyopathy. Which should the nurse assess prior to obtaining the arterial blood sample? Ulnar blood flow. Apical heart rate. Oxygenation level. Breath sounds. A client returns to the postoperative unit after arteriovenous graft placement. The telemetry is showing tall, peaked T waves on the waveform. Which action should the nurse implement? Review the client's recent serum potassium level. Prepare the client for synchronize cardioversion. Notify Rapid Response Team for ST-elevation myocardial infarction. Move the telemetry leads to the correct placement on the chest. A client who is hypotensive is receiving an infusion of dopamine 10 mcg/kg/minute IV through a peripheral line. The client begins to report burning at the IV site. Which action should the nurse implement? Stop the infusion and notify the healthcare provider of the findings. Check the line for blood return and irrigate the peripheral IV catheter. Apply a cold compress to the site and continue the infusion's rate. Slow the infusion rate and add a secondary IV of 0.9% sodium chloride. The nurse is caring for a client who is recently extubated in the post anesthesia care unit (PACU). The client has humidified oxygen per mask and suddenly develops stridor and respiratory difficulty. Which action should the nurse implement? Call a rapid response team for emergency airway management. Encourage the client to take deep breaths,cough, and expectorate. Increase the flow rate of the humidified oxygen. Suction the client's mouth and oropharynx thoroughly. An older client is admitted to the intensive care unit after a small bowel resection. The postoperative prescriptions include a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide the client about the use of the PCA? Push button when pain is first experienced instead of waiting until pain is unbearable. Family members or visitors can press the button when the client grimaces in pain. Press the button every 15 minutes even when pain is not present. The paramedics bring in a client who is a victim of a high speed motor vehicle collision. The client is semi-coherent, fading in and out of consciousness. Two large bore intravenous catheters have been put in place, and one is infusing with normal saline at 100 mL/hr. Which information is the most important for the triage nurse to obtain from the paramedics? The victim's vital signs upon arrival on the scene. Status of the other victims involved in the accident. Description of the motor vehicle collision circumstances. Police custody status of the victim pending further investigation. A client reports shortness of breath and chest pressure radiating down the left arm. The client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first? Give0.3 mg nitroglycerin sublingual. Administer4 mgIV morphine sulfate. Measure the ST segment height. Infuse 0.9% sodium chloridebolus A client diagnosed with gastric ulcers is admitted for a cauterization procedure. Which finding(s) should the nurse report to the healthcare provider? (Select all that apply.) Decreased level of consciousness. Hypoactive bowel sounds. Decreased urine output. Coffee-ground vomitus. Positive guaiac stools. The nurse is caring for a client who underwent surgical repair of the aorta after sustaining injuries in a fall. Which finding indicates improved blood flow after the surgery? Movement of lower extremities. Decreased urinary output. Maintained weight. Blood pressure 90/50. . The nurse receivesreport for a client with a history of heroin and alcohol abuse who has right arm cellulitis from a puncture wound. 0.9% sodium chloride is infusing at 50 mL/hr and oxygen at 2 liters per nasal canula. The client is flushed, diaphoretic, and slow to respond to verbal stimuli. Vital signs include oxygen saturation 94%, temperature 101° F (38.3° C), heart rate 124 beats/minute, respirations 26 breaths/minute, and blood pressure 88/24 mmHg. Which intervention should the nurse implement first? Administer antipyretic suppository. Obtain 2 sets of blood cultures. Increase IV fluids to 150 mL/min. Monitor client for withdrawal signs. The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation due to acute respiratory failure. The family asks when the client will be extubated. Which information should the nurse provide? When the client performs spontaneous breathing in between mechanical ventilation. Once all serum electrolyte and blood chemistry levels normalize. At the completion of intravenous antibiotic therapy and the infection is resolved. When the chest x-ray shows that the inflammation is resolved. The nurse is caring for a client who is diagnosed withdiabetic ketoacidosis (DKA). The client reports abdominal pain and nausea, and presents with fruity-scented breath. The nurse performs a finger stick blood glucose with a reading too high to register. Which intervention is most important for the nurse to implement? Initiate a one liter bolus of 0.9% sodium chloride. Set up an IV pump to infuse IV insulin per protocol. Draw blood to evaluate a complete metabolic panel. Administer a prn IV dose of prescribed antiemetic. A client diagnosed with an end-stage terminal illness has decided to discontinue treatment. The client has become very detached and does not want to participate in the plan of care. Which action should the nurse implement first? Initiate a referral for a mental health consultation. Encourage the client to participate in their plan of care. Review the client's medical record for documented religious preference. Contact the hospital chaplain to provide spiritual counseling and guidance. The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which intervention should the nurse implement? Assess for signs of cardiac tamponade. Begin chest compressions at 120 per minute. Check for responsivenesswith sternal rub. Obtain a STAT 12 lead electrocardiogram. The nurse assists the healthcare provider with the insertion of a pulmonary artery (PA)catheter for a client presenting with cardiogenic shock. Which action is most important for the nurse to take to prevent life-threatening complications from pulmonary artery monitoring? Fast flush the PA distal port for no more than 2 seconds. Avoid infusing blood products through the PA catheter. Clear pressure tubing of any blood afterwithdrawing a sample. Maintain 300 mmHg pressurearound thebagattached to the tubing. The nurse is caring for a client in the critical care unit who is experiencing end-stage chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at 40 L/minute via Vapotherm. The healthcare provider informs the client and family that there is no further treatment available for the COPD. Which intervention should the nurse recommend that is most beneficial to the client and family? Hospice services. Intubation with mechanical ventilation. Organ donation. Home health care. A client who has experienced trauma is admitted to the intensive care unit (ICU). The nurse's initial assessment findings include a Glasgow Coma Scale score of (3), pupils fixed and dilated with an absence of corneal reflex, blood pressure of 80/30 mmHg, core temperature of 95.7°F (35.4° C). The client's spouse asks the nurse when the client will wake up. How should the nurse respond? "Your spouse's condition indicates irreversible damage." "Let me contact the health care provider to answer your questions." "Each person is different and we need to wait and see what happens." "I need to initiate the volume expanders and warming blanket to stimulate a response The nurse is analyzing an arterial blood gas (ABG) of a client who has a nasogastric tube to low suction. The ABG results are pH - 7.48; paCO 2 - 50 mmHg; HCO 3 - 27mEq/liter. How should the nurse interpret this blood gas? Partially compensated respiratory acidosis. Partially compensated respiratory alkalosis. Partially compensated metabolic acidosis. Partially compensated metabolic alkalosis. The emergency department nurse is triaging a client whose spouse reports a sudden onset of symptoms to include fever, tremors, and decreased level of orientation and psychotic behavior, accompanied with the tachycardia and palpitations. The only significant medical history of the client is 4 days post-operative laparotomy appendectomy without complications and discharged to home 2 days ago. Which intervention should the nurse do first? Initiate a large bore intravenous catheter. Perform a twelve-lead electrocardiogram test. Insert an indwelling urinary catheter drainage system. Obtain serum elctrolytes and kidney function test laboratory specimens. A client's blood pressure drops suddenly from 160/90 mmHg to 60/40 mmHg minutes after the nurse administers a 0.3 mg sublingual dose of nitroglycerin when the client reports crushing chest pain. The client is experiencing severe nausea, dizziness, and left arm numbness. Which intervention should the nurse implement? Give a PRN antiemetic medication. Administer second dose of nitroglycerin. Infuse a rapid0.9% normal saline bolus. Applyexternal pace maker pads to chest. A male client who experienced a myocardial infarction (MI) asks the nurse what could have caused the MI, since he had been following a lifestyle of regular exercise and healthy food choices. Which response should the nurse provide to the client? A family history of heart disease is a risk factor for MI. Foods consumed when younger can cause plaque formation. Immediate medical treatment was a primary factor is survival. Myocardial tissue after a minor MI can heal with no long-term effects. What is the nurse's priority action for a client with this ECG tracing? Call the rapid response team and start compressions. Notify the provider for further orders. Have the client perform Valsalva maneuvers. Document the rhythm as the only finding. What action should the nurse implement for a client with this ECG tracing. Document the rhythm. Notify the provider immediately. Administer drugs per Advanced Cardiac Life Support protocol. Call the family and ask if a chaplain should be summond. Which laboratory test results should the nurse review for a client with this ECG tracing? Basal metabolic panel (BMP), serum Magnesium, and serum Phosphorus. Lactic Acid Cardiac enzymes and Troponins. Complete blood count. A client's cardiac rhythm reveals peaked "T" waves, a widening "QRS" complex and the flattening of "P" waves. Which medication should the nurse administer? Phosphate IV push. Furosemide IV push. Calcium gluconate IV push. Diluted potassium IV push. The nurse is caring for a client who is prescribed a potassium-sparing diuretic and has a potassium level of 6.1 mEq/L (6.1 mmol/L). Which intervention should the nurse perform? Obtain a 12-lead electrocardiogram (ECG). Call a rapid response. Insert an intravenous (IV) line. Schedule a cardiac catheterization. [Show More]

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