Exit HESI: Critical Care Quiz
A client's cardiac monitor indicates ventricular tachycardia. The nurse assesses the client and identifies an increase in apical pulse rate from 100 to 150 beats/minute. Which action is indicated? A. Administer amiodarone. B. Administer epinephrine. C. Assist with insertion of a pacemaker. D. Administer atropine.
A. Administer amiodarone. Amiodarone suppresses ventricular activity; therefore it is used for treatment of premature ventricular complexes (PVCs) and ventricular tachycardia. It works directly on the heart tissue and slows the nerve impulses in the heart. Epinephrine hydrochloride is not used for ventricular tachycardia (VT) with a pulse and may even precipitate ventricular fibrillation. A pacemaker is used for symptomatic bradycardia and heart blocks. Atropine is used to treat bradycardia.
A client at 37 weeks' gestation is in the emergency department after a motor vehicle accident. Vital signs upon admission are BP 110/72 mm Hg, HR 98 beats/min. The client begins complaining of sudden, sharp abdominal pain, and repeated vital signs are BP 90/60 mm Hg, HR 108 beats/min. Which nursing intervention is the priority at this time? A. Apply an electronic fetal monitor. B. Prepare for a possible cesarean birth. C. Draw blood for a type and cross-match. D. Assess the amount of vaginal bleeding.
A. Apply an electronic fetal monitor. Applying the fetal monitor will allow quick assessment of fetal condition so that appropriate treatment can be instituted immediately. The client's clinical manifestations suggest abruptio placentae. Other interventions may be done simultaneously, depending on the urgency. Preparing for an emergent cesarean section, drawing blood for type and cross-match, and assessing for vaginal bleeding are critical next steps.
Which actions would the nurse expect to take for a client who has compartment syndrome? Select all that apply. A. Assisting with splitting the cast B. Monitoring urine output C. Evaluating pain using a pain scale D. Applying splints to the injured part E. Placing cold compresses to the affected area
A. Assisting with splitting the cast B. Monitoring urine output C. Evaluating pain using a pain scale Compartment syndrome is increased pressure in a limited space, which compromises the compartmental blood vessels, nerves, and tendons. The cast may be split to reduce the external circumferential pressures. The nurse would assess urine output because the myoglobin released from damaged muscle cells may precipitate and cause obstruction in renal tubules. The nurse would evaluate the pain on a scale from 0 to 10; this helps plan care. Application of external pressure by splints, casts, and dressing to the injured area may worsen the client's symptoms. Application of cold compresses may result in vasoconstriction and exacerbate the symptoms.
After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. A. Confusion B. Hypocapnia C. Tachycardia D. Constricted pupils E. Slow respiratory rate
A. Confusion B. Hypocapnia C. Tachycardia Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.
The nurse is assessing a client 12 hours after the client sustained a deep partial-thickness burn on the forearm. Which characteristics would the nurse expect to identify when assessing the injured tissue? A. Painful and reddish-white B. Pinkish and tender C. Charred and white D. Leathery and black
A. Painful and reddish-white Deep partial-thickness burns involve some injury to the epidermis and dermis, characterized by pain and red-to-white tissue color. Pinkish and tender describes a superficial partial-thickness burn. The characteristics charred, white, leathery, and black describe a full-thickness burn.
Which clinical finding is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block? A. Syncope B. Headache C. Tachycardia D. Hemiparesis
A. Syncope With complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the sinoatrial (SA) node. As a result, there is decreased cerebral circulation, causing syncope. Headache is not related to heart block. The heart rate usually is slow (not increased as in tachycardia) because the SA node does not initiate the ventricular rhythm. Hemiparesis is associated with a stroke (cerebrovascular accident).
Which type of damage is most likely caused by a crush injury to victims of a terrorist attack involving explosive devices? A. Middle ear injury B. Blunt trauma to the head C. Shrapnel injury in the abdomen D. Damaged lungs due to shock wave
B. Blunt trauma to the head Crush injuries often result from explosions in confined spaces causing structural collapse, such as falling debris. Blunt trauma to the head is an example of a crush injury. Middle ear injury is a common type of blast injury that results from the supersonic over pressurization shock wave caused by the explosion. Some explosive devices contain materials that are projected during the explosion, leading to penetrating injuries. Shrapnel injury in the abdomen is a type of penetrating injury. Lung damage due to a shock wave is a type of blast injury.
Which conditions of clients who have been exposed to cold temperatures in a snowstorm put them at a high risk of sustaining cold injuries? Select all that apply. A. Dehydration B. Hypoglycemia C. Opioid medication use D. A heavy smoker for years E. Thyrotoxicosis
B. Hypoglycemia C. Opioid medication use D. A heavy smoker for years Hypoglycemia is a cause of hypothermia. Medications that suppress shivering, such as opioids, can be a contributing factor for cold injury. Smokers have an increased risk of cold-related injury because of the vasoconstrictive effects of nicotine. Dehydration is a metabolic cause of hyperthermia. Thyrotoxicosis can make a client susceptible to hyperthermia.
Which conditions of the client with chronic pain who is on opioid treatment would the nurse consider as the highest priority? Select all that apply. A. Pruritus B. Level 3 sedation C. Constipation D. Respiratory rate of 8 breaths per minute E. Nausea and vomiting
B. Level 3 sedation D. Respiratory rate of 8 breaths per minute Chronic use of opioids for pain may lead to constipation, nausea, vomiting, sedation, and respiratory distress. The client with a level 3 of sedation has frequent drowsiness, arousals, and episodes of sleep during conversation and needs immediate intervention. A respiratory rate of 8 breaths per minute leads to respiratory distress, which must be supported by adequate oxygenation. Pruritus can be resolved slowly because it is less life threatening. Constipation can be relieved by providing the client with a stimulant laxative and a stool softener. Nausea and vomiting may be resolved by providing antiemetics to the client.
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)? A. Prevent cataracts B. Prevent blindness C. Prevent retinal detachment D. Prevent blurred distance vision
B. Prevent blindness POAG progresses gradually without symptoms; if untreated, blindness occurs. Peripheral vision slowly disappears until tunnel vision occurs in which there is only a small center field. Without treatment, eventually all vision is lost. POAG is not related to the development of cataracts, retinal detachment, or blurred distance vision.
Which rationale explains why the nurse would monitor a client who has a spinal cord injury at the T2 level for signs of autonomic hyperreflexia (autonomic dysreflexia)? A. The injury results in loss of the reflex arc. B. The injury is above the sixth thoracic vertebra. C. There has been a partial transection of the cord. D. There is a flaccid paralysis of the lower extremities.
B. The injury is above the sixth thoracic vertebra. The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.
The nurse notes blood pressure of 200/110 mm Hg and swelling of the operative leg for a client who has had a femoropopliteal bypass graft. Which action would the nurse take next? A. Evaluate the client's orientation. B. Check pedal pulses distal to the graft. C. Notify the client's health care provider. D. Monitor blood pressure every 15 minutes.
C. Notify the client's health care provider. Because the high blood pressure and leg swelling indicate possible graft leaking or rupture, the nurse would immediately notify the health care provider and anticipate measures to lower blood pressure or possible transfer of the client to the operating room. Evaluation of the client's orientation is appropriate, but not as essential as addressing possible arterial bleeding at the graft site. Checking pedal pulses is part of the postoperative care plan, but will not address the possible graft leaking or rupture. The nurse will continue to monitor blood pressures frequently, but immediate intervention is needed to lower blood pressure and decrease graft leaking or rupture.
Which steps would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. A. Induce gastric lavage. B. Give ipecac syrup to the client. C. Turn the head of the client to the side. D. Empty the mouth to clean the residue of the drug. E. Call local poison control center before any intervention.
C. Turn the head of the client to the side. D. Empty the mouth to clean the residue of the drug. E. Call local poison control center before any intervention. The nurse would turn the head of the client to the side to avoid aspiration. The nurse would empty the mouth if there is any remaining drug. If the victim is conscious and alert, the nurse would call the local poison control center or the national toll-free poison control center number before attempting any intervention. The nurse would refrain from inducing vomiting in the client because there is a risk of aspiration. Ipecac syrup causes vomiting, so it is no longer recommended for routine treatment of poisoning.
Which action would the nurse take when caring for a client with burns who is being treated with collagenase and polysporin powder therapy? A. Apply the treatment twice a day. B. Monitor arterial blood gas levels. C. Use the treatment on partial-thickness wounds with eschar. D. Avoid a barrier dressing such as occlusive petrolatum gauze.
C. Use the treatment on partial-thickness wounds with eschar. Collagenase with polysporin powder should be used on partial-thickness wounds with eschar. It should be applied once a day. During the administration of mafenide acetate, arterial blood gas levels should be monitored. Collagenase with polysporin powder should be used with a barrier dressing such as occlusive petrolatum gauze.
Which statement made by the student nurse indicates effective knowledge regarding mass casualty incidents (MCIs)? A. "Two-thirds of victims are generally tagged red or black." B. "The triage of victims of an MCI must be conducted in 1 minute." C. "Victims who arrive at the hospital on their own are not considered during triage." D. "The total number of victims can be estimated by doubling the number of victims who arrive in the first hour."
D. "The total number of victims can be estimated by doubling the number of victims who arrive in the first hour." The total number of victims a hospital can expect is estimated by doubling the number of victims who arrive in the first hour. In general, two-thirds of victims are tagged green or yellow, and the rest of them are tagged red or black. Triage of victims of an MCI must be conducted in less than 15 seconds. Victims who arrive at the hospital on their own are known as "walking wounded" and are considered during triage.
Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns? A. Provide a diet high in sodium. B. Limit caloric intake to decrease the work of the body. C. Reduce protein intake to avoid overtaxing the kidneys. D. Administer the prescribed intravenous fluid with the added vitamin C.
D. Administer the prescribed intravenous fluid with the added vitamin C. Vitamin C is essential for wound healing. It provides a component of intercellular ground substance that develops into collagen and is necessary to build supportive tissue. To prevent excessive fluid retention, which will increase the cardiovascular workload, sodium intake should be regulated. Decreasing calories will promote catabolism of body tissue; caloric need is increased. Protein intake should be increased to help repair damaged tissue.
The nurse observes abnormal rigidity with pronation of the arms and plantar flexion while assessing a client. Which condition would the nurse record in the assessment findings? A. Decortication B. Pronator drift C. Babinski sign D. Decerebration
D. Decerebration Abnormal movement with rigidity on extension of the arms and legs, pronation of the arms, and plantar flexion is called decerebration. The condition found in the client related to decerebration should be recorded in the assessment findings. Decortication is abnormal movement in which arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs. Pronator drift is the drifting of the arm on pronating the palm. Babinski sign is dorsiflexion of the great toe and fanning of the other toes when the sole of the foot is stroked.
Which effect is seen in clients exposed to sarin? A. Acute radiation syndrome B. Paralysis of cardiac muscles C. Burns and blisters on the skin D. Paralysis of respiratory muscles
D. Paralysis of respiratory muscles Sarin is a highly toxic nerve gas that can cause death within minutes of exposure. It acts by paralyzing the respiratory muscles. Acute radiation syndrome is caused by a substantial exposure to ionizing radiation; sarin is unrelated to ionizing radiation. Sarin causes paralysis of respiratory muscles, not cardiac muscles. Burns and blisters on the skin are caused by mustard gas.
Which action of the emergency department nurse caring for a group of clients injured in a community disaster would need correction? A. Triaging the victims B. Supervising volunteers C. Providing on-site first aid D. Removing people from danger
D. Removing people from danger During a community disaster, removing people from danger is done by firefighters and other disaster trained emergency personnel. Nurses would not be involved in this process. After the removal of people from danger, the nurses triage the victims under triage categories. The nurses supervise volunteers and provide on-site first aid to victims.
A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit? A. Tremors B. Anasarca C. Bradypnea D. Tachycardia
D. Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurological problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.
When a client's cardiac rhythm strips shows more P waves than QRS complexes and there is no relationship between the atria and the ventricles, how would the nurse document the rhythm? A. First degree atrioventricular (AV) block B. Second degree AV block Mobitz I (Wenckebach) C. Second degree AV block Mobitz II D. Third degree AV block (complete heart block)
D. Third degree AV block (complete heart block) Third-degree block often is called "complete heart block" because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third- degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS, but the PR interval is prolonged beyond 0.2 seconds. Second-degree AV block type I, also called Mobitz I or Wenckebach heart block, is represented on the electrocardiogram (ECG) as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception. However, some P waves are not followed by a QRS.
Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). Which action would the nurse take to reduce the possibility of retinopathy of prematurity? A. Humidifying oxygen flow to prevent dehydration B. Uncovering the entire body to increase exposure to the oxygen C. Applying eye patches to both eyes to protect them from the oxygen D. Verifying oxygen saturation frequently to adjust flow on the basis of need
D. Verifying oxygen saturation frequently to adjust flow on the basis of need Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.
