Review HESI: Critical Care

A client develops an anaphylactic reaction after receiving morphine. The nurse should plan to institute which actions? Select all that apply. Administer oxygen. Quickly assess the client's respiratory status. Document the event, interventions, and client's response. Leave the client briefly to contact a health care provider (HCP). Keep the client supine regardless of the blood pressure readings. Start an intravenous (IV) infusion of D5W and administer a 500-mL bolus.

Administer oxygen. Quickly assess the client's respiratory status. Document the event, interventions, and client's response.

The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? Hold the defibrillator paddles firmly against the chest. Apply adhesive patch electrodes to the chest and move away from the client. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device. Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm.

Apply adhesive patch electrodes to the chest and move away from the client. Rationale: The nurse or rescuer puts two adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse stops CPR and requests that anyone near the client move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates whether defibrillation is necessary.

The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure? Radial artery Carotid artery Brachial artery Popliteal artery

Brachial artery Rationale: To assess a pulse in an infant (younger than 1 year), the pulse is checked at the brachial or femoral artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant.

The normal therapeutic range for digoxin is

0.5 to 0.8 ng/mL

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen test on the client. The nurse would perform the steps in which order to conduct an Allen test?

1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries. 3. Ask the client to open and close the hand repeatedly. 4 Release pressure from the ulnar artery. 5. Assess the color of the extremity distal to the pressure point. 6. Document the findings.

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should perform how many ventilations per minute at which pressure?

40 to 60 breaths/min, 15 to 20 cm H2O pressure Rationale: If the newborn is apneic or has gasping respirations after stimulation or if the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O.

The heart normally pumps _______ of blood every minute.

5 L

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? Heart failure Pulmonary edema Cardiogenic shock Aortic insufficiency

Cardiogenic shock Rationale: IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of IABP therapy is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema.

The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? Prepare epinephrine. Charge the defibrillator. Check the client's heart rhythm. Pause CPR for 20 seconds and reassess.

Charge the defibrillator. Rationale: For witnessed adult cardiac arrest when a defibrillator is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom a defibrillator is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use. After completing 5 cycles of compressions and ventilations, the nurse should reassess the client by checking the heart rhythm. Defibrillation may be warranted depending on the assessed rhythm. Epinephrine may be prepared depending on the rhythm, but this would be prescribed by a health care provider (HCP). Chest compressions should not be interrupted for more than 10 seconds.

The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? Cooling the injury with water Removing all clothing immediately Removing the tar from the burn injury Leaving any clothing that is saturated with tar in place

Cooling the injury with water Rationale: Scald burns and tar or asphalt burns are treated by immediate cooling with saline solution or water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene.

The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? Cut the tube. Reposition the client. Assess the lumens of the tubes. Administer the prescribed analgesics.

Cut the tube. Rationale: Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are possible complications associated with a Sengstaken-Blakemore tube. Esophageal rupture also may occur and is characterized by the abrupt onset of severe pain. In the event of any of these life-threatening emergencies, the tube is cut and removed.

The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment? Diminished breath sounds Wheezing during inhalation Wheezing during exhalation Wheezing throughout the lung fields

Diminished breath sounds Rationale: Diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration.

A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? Applying a nonrebreather mask Discontinuing the infusion after 24 hours Monitoring the cardiac rhythm every hour Administering the IV bolus over 2 to 3 seconds

Discontinuing the infusion after 24 hours Rationale: Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be administered for up to 24 hours. Therefore, the nurse should prepare to discontinue the infusion after 24 hours. Upon discontinuation of infusion, heart rate reduction may last from 0.5 hours to more than 10 hours (median duration 7 hours). A nonrebreather mask is not necessary. The client's cardiac rhythm is monitored continuously

The nurse is caring for a client who overdosed on acetylsalicylic acid (aspirin) 24 hours ago. The nurse should expect to note which findings associated with an anticipated acid-base disturbance? Disorientation and dyspnea Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias Decreased respiratory rate and depth, cardiac irregularities

Drowsiness, headache, and tachypnea Rationale: The client who ingests a large amount of acetylsalicylic acid (aspirin) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea.

The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? Elevate the head of the bed. Monitor oxygen saturation levels every 4 hours. Encourage coughing and deep breathing every 4 hours. Assess respiratory rate and breath sounds every 4 hours.

Elevate the head of the bed.

An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply. Ensure a patent airway. Obtain a throat culture. Maintain the child in a supine position. Obtain a pediatric-size tracheostomy tray. Prepare the child for a chest radiographic study. Place the child on an oxygen saturation monitor.

Ensure a patent airway. Obtain a pediatric-size tracheostomy tray. Prepare the child for a chest radiographic study. Place the child on an oxygen saturation monitor. Rationale: Acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention. The nurse immediately ensures a patent airway. To reduce respiratory distress, the child should sit upright. Examining the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because it could precipitate further obstruction. A complete blood count is obtained, and the child is placed on an oxygen saturation monitor. Lateral neck and chest radiographic films are obtained to determine the degree of obstruction, if present. A pediatric-size tracheostomy tray should be readily available, and intubation may be necessary if respiratory distress is severe.

A client receiving total parenteral nutrition (TPN) through a single-lumen central intravenous (IV) line is scheduled to receive an antibiotic by the IV route. Which action by the nurse is appropriate before hanging the antibiotic solution? Ensure a separate IV access for the antibiotic. Turn off the solution for 30 minutes before administering the antibiotic. Flush the central IV line with 60 mL of normal saline before giving the antibiotic. Check with the pharmacy to be sure the antibiotic can be given through the TPN solution line.

Ensure a separate IV access for the antibiotic. Rationale: The TPN solution line is used only for the administration of the solution. Any other IV medication must be run though a separate IV access site; therefore, the remaining options are incorrect.

The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? Administer oxygen to the woman. Transport the woman to the delivery room. Place an external fetal monitor on the woman. Exert upward pressure against the presenting part.

Exert upward pressure against the presenting part. Rationale: If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place.

The long-term care nurse about to give a daily dose of digoxin is told that a serum digoxin level drawn earlier in the day measured 1.4 ng/mL (1.7 nmol/L). Which action should the nurse take first? Administer the daily dose of the medication. Report the finding to the health care provider (HCP). Record the normal value on the intershift report sheet. Gather data from the client related to signs of toxicity.

Gather data from the client related to signs of toxicity. The nurse should gather data about signs of digoxin toxicity first and then notify the HCP.

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner? Mixed in solution with the IV antibiotics Giving it slowly over 30 to 90 minutes Piggybacked into the packed red blood cells Giving it rapidly over 5 minutes by IV bolus

Giving it slowly over 30 to 90 minutes Rationale: Mannitol is an osmotic diuretic. When used to treat increased ICP, it is given slowly over 30 to 90 minutes, not rapidly and not via IV bolus. Mannitol should not be mixed in solution with antibiotics, and nothing should be piggybacked with packed red blood cells.

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? Insertion of a Foley catheter Insertion of a nasogastric tube Administration of an anesthetic agent for sedation Application of an antimicrobial agent to the burns

Insertion of a Foley catheter Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed after assessment, but this would not be the initial action. Intravenous fluids are administered at a rate sufficient to keep the child's urine output at 1 to 2 mL/kg of body weight per hour for children weighing less than 30 kg, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention.

The nurse in the hospital emergency department is preparing to administer fomepizole to a client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this medication by which route? Oral route Intramuscular route Intravenous (IV) route Through a nasogastric tube

Intravenous (IV) route

The nurse is admitting a young child who arrived from the emergency department after treatment for acetaminophen overdose. After administering the antidote, the nurse should reassess the child, including which priority laboratory value? Thyroid panel Urine drug screen Liver function panel Kidney function tests

Liver function panel

A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply. Monitor vital signs. Monitor the client's airway. Apply manual pressure over the site. Lower the head of the bed to a flat position. Call the health care provider (HCP) immediately.

Monitor vital signs. Monitor the client's airway. Apply manual pressure over the site. Call the health care provider (HCP) immediately. Rationale: If the client begins to hemorrhage from the surgical site after radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site and calls the HCP immediately. The nurse also monitors the client's airway and vital signs.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication associated with TPN? Weighing the client daily Monitoring the temperature Monitoring intake and output (I&O) Monitoring the blood urea nitrogen (BUN) level

Monitoring the temperature Rationale: The most common complication associated with TPN is infection. Monitoring the temperature provides assessment data that would indicate infection in the client.

A client with type 1 diabetes mellitus in the emergency department is diagnosed with diabetic ketoacidosis (DKA). Which interventions should the nurse anticipate being prescribed initially? Select all that apply. Monitoring urine for ketones Intravenous potassium replacement Administration of intravenous insulin A bolus of 5% dextrose intravenously Administration of a liter of 0.9% NaCl intravenously.

Monitoring urine for ketones Intravenous potassium replacement Administration of intravenous insulin Administration of a liter of 0.9% NaCl intravenously.

The nurse reviewing the operative record for a client who has just undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. Which intervention is appropriate based on the client's cardiac output reading? Notify the health care provider (HCP). Continue to monitor the cardiac output. Place the client in the shock position. Increase the intravenous (IV) fluid rate.

Notify the health care provider (HCP).

A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? Place the child in a supine position. Notify the health care provider (HCP). Place the child in Trendelenburg's position. Increase the flow rate of the intravenous fluids.

Notify the health care provider (HCP). Rationale: In the event of shock, the HCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed in the supine or Trendelenburg's position because it increases intracranial pressure (ICP) and the risk of bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? On the left side, with the head lower than the feet On the left side, with the head higher than the feet On the right side, with the head lower than the feet On the right side, with the head higher than the feet

On the left side, with the head lower than the feet Rationale: Air embolism occurs when air enters the catheter system, such as when the system is opened for intravenous (IV) tubing changes or when the IV tubing disconnects. Air embolism is a critical situation; if it is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. The positions in the remaining options are inappropriate if an air embolism is suspected.

A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart? Phentolamine Protamine sulfate Calcium gluconate Phenobarbital sodium

Phentolamine Rationale: The antidote for hypertensive crisis is phentolamine. Hypertensive crisis may be manifested by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain also may be present.

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? Call the health care provider (HCP). Place the tube in a bottle of sterile water. Replace the chest tube system immediately. Place a sterile dressing over the disconnection site.

Place the tube in a bottle of sterile water. Rationale: If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.

A client with pancreatitis is being weaned from total parenteral nutrition (TPN). The client asks the nurse why the TPN cannot just be stopped. What is the nurse's best response? Dehydration can result. Hypokalemia may occur. Hypernatremia will occur. Rebound hypoglycemia is a risk.

Rebound hypoglycemia is a risk. Rationale: Clients receiving TPN are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the TPN, the body must adjust to the lowered glucose level. If the TPN were suddenly withdrawn, the client could have rebound hypoglycemia.

A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? Remove the dressing. Reinforce the dressing. Call the health care provider (HCP). Measure oxygen saturation by oximetry.

Remove the dressing. Rationale: Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occur, the nurse should remove the dressing immediately, allowing air to escape. Therefore, reinforcing the dressing is an incorrect action. The nurse would measure oxygen saturation by oximetry and would call the HCP, but these would not be the first actions in this situation

The nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-retaining diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, should the nurse contact the health care provider to obtain? Daily electrolytes A 12-lead electrocardiogram Resume the client's dose of metoprolol Insertion of an indwelling urinary catheter

Resume the client's dose of metoprolol Rationale: According to The Joint Commission's Surgical Care Improvement Program's core measures, surgery clients on beta-blocker therapy prior to surgery should receive a beta blocker within 24 hours of surgery.

A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse should take? Stop the infusion. Change the dressing bandage. Remove the epidural catheter. Notify the health care provider (HCP).

Stop the infusion. Rationale: If a client complains of a sudden headache and clear drainage is present near the epidural insertion site, it is possible that the catheter has migrated. The immediate actions by the nurse are to stop the infusion and then to notify the HCP. The HCP needs to be notified, but the nurse can delegate that task to a colleague while caring for the client.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? Stridor Occasional pink-tinged sputum Respiratory rate of 24 breaths/minute A few basilar lung crackles on the right

Stridor Rationale: Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction.

An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action? The ratio of compressions to ventilations is 30:2. The carotid pulse is palpable with each compression. Respirations are given at a rate of 10 breaths per minute. The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm).

The carotid pulse is palpable with each compression. Rationale: With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital. Assessment of the carotid pulse during CPR is the most accurate way to assess the effectiveness of CPR. Correct procedure for CPR in an adult includes a compression-to-ventilation ratio of 30:2. With adults, compressions are performed at a depth of at least 2 inches (5 cm). The 30:2 compression-to-ventilation ratio yields an effective rate of 10 breaths per minute.

A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse should assess for which condition? Dyspnea Bradycardia Hypertension Ventricular ectopy

Ventricular ectopy

The nurse is performing discharge teaching for a client with a peripherally inserted central catheter (PICC). Which instructions should the nurse include? Select all that apply. Wear a MedicAlert tag or bracelet. Report redness or swelling at the catheter insertion site. Have a repair kit available in the home for use if needed. Keep activity level to a minimum while this catheter is in place. Cover the PICC dressing with plastic when in the shower or bath.

Wear a MedicAlert tag or bracelet. Report redness or swelling at the catheter insertion site. Have a repair kit available in the home for use if needed. Cover the PICC dressing with plastic when in the shower or bath.

The nurse is making a note in the care plan for a client who has a multilumen central venous catheter. The nurse should write to change the injection caps on the lumens at which times? Once a week At the change of each shift After administration of each medication Whenever blood is drawn from the lumen

Whenever blood is drawn from the lumen Rationale: Changing the injection caps is done to reduce systemic infection, which can be caused by contaminated caps. The injection cap should be discarded and a new one applied once it has been removed from the actual lumen. It is removed whenever blood work is drawn from the lumen. Once a week is too infrequent. At the change of shift is too frequent. It is not necessary to change the injection caps after administration of each medication because it is unnecessary to remove the cap to administer medication. In addition, agencies have policies that guide the frequency of routine injection cap changes (often every 48 hours).