HESI Case Study ACLS

The client's spouse inquires about the client's blood sugar because she has never seen it that high. and she reports that the client isn't even eating. What is the nurse's best response?

"Stress can increase blood sugar"

What is the nurse's first action?

Assess the client

Which is the primary reason for administering epinephrine 1 mg every 3 to 5 minutes during a cardiac arrest?

Increases cardiac output

One hour has passed since the client was extubated. Which nursing actions take priority at this time? (select all that apply)

Monitor respiratory rate Assess cardiac rhythm

The client's spouse asks why the antibiotic is being delayed to obtain lab tests. What is the nurse's best response?

"It improves the chance of identifying the bacteria that is making your husband sick"

In what sequence should the nurse carry out the prescriptions?

1. Hang normal saline 2. Collect blood and urine cultures 3. Administer piperacillin/tazobactam 4. Insert indwelling catheter

The nurse assessing the client's carotid artery reports no pulse is found. What is the nurse's priority action?

Activate a code

Thirty minutes after ending the code, Mr.Azizi succumbs to his illness.HIs spouse is crying uncontrollably. She begins to talk about how she is going to have a hard time without her husband of 30 years. What is the nurses most therapeutic response?

Actively listen as she speaks

Based on the nurse's assessment, which is the priority nursing action?

Administer morphine

The nurse is caring for the client who has just been extubated. What should the nurse do first, after the client is extubated?

Administer supplemental oxygen

Using the American Heart Association's Basic Cardiac Life Support (BLS) algorithm, what is the nurse's priority action?

Assess carotid artery

After shocking the clients chest, what is the nurses next action?

Begin chest compressions

Upon reviewing the remaining postoperative prescriptions and comparing with preoperative prescriptions, the nurse realizes that the metformin doses are different. What is the nurse's priority action?

Contact the HCP for clarification

The nurse is aware that the older adult client is at an increased risk for surgical complications due to normal physiological functions and comorbidities. Which risk factors place the older adult client at increased risk for surgical complications?

Decreased respiratory muscle strength

The client remains in pulseless ventricular tachycardia and is unresponsive. The team intubates him and administers the second shock. What medication does the nurse anticipate administering after the second shock?

Epinephrine

Upon completing the client's assessment, the nurse determines that the client has which surgical risk factors? (Select all that apply.)

Metoprolol Poor appetite Diabetes mellitus Albumin 3.0 g/dL

After giving report, the nurse transfers Mr. Azizi back to the MICU. Which of the client's signs and symptoms cue the MICU nurse to determine if the client continues to have sepsis? (select all that apply)

Hypothermia Altered mental status Tachycardia Leukocytosis Tachypnea

Which is the primary cause of respiratory alkalosis?

Hypoxemia related to acute lung disorders

What is the priority preoperative nursing action to prevent postoperative atelectasis?

Instruct on incentive spirometer use

After reviewing the client's assessment data, what is the nurse's priority action?

Notify the HCP fo the findings

The nurse knows that the client is in which acid-base imbalance?

Respiratory alkalosis

The code team arrives with the crash cart. The carotid artery is reassessed and there is still no pulse. Cardiac leads are placed and pulseless ventricular tachycardia is confirmed. What is the priority nursing action?

Shock the clients chest

Despite the teams efforts, Mr.Azizi remains unresponsive and the telemetry monitor shows asystole. Mrs. Azizi, who has been in the room the entire time, asks the team to stop. She cannot bear to see her husbands chest "crushed" anymore. What is the nurses best response?

Stop coding the client

Which is the likely reason for the elevated serum creatinine in the absence of kidney disease?

dehydration