Adult Health 3 HESI Critical Care 2 Questions And Correct Detailed Answers (Verified Answers) Already Graded A

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Adult Health 3 HESI Critical Care 2 Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

• The emergency room nurse is informed by the Emergency Medical Services (EMS)

that a client with an acute anterior myocardial infarction and ST elevation (STEMI) on ECG will be treated with percutaneous coronary intervention (PCI) immediately upon arrival. What should the nurse do to best assist this client?

• Administer t-PA (alteplase).
• Administer epinephrine.
• Administer aspirin and clopidogrel.
• Withhold morphine sulfate.

Correct Answer: C

• The nurse has completed an assessment on a client who is being admitted to the

ICU. After receiving orders from the HCP, what should the nurse implement first?

Correct Answer: Start broad spectrum antibiotic therapy

• At the start of a new shift the nurse receives laboratory results for a client who

recently arrived in the emergency department: Na+ 152 mEQ/L, K 4.8 mEq/L, HCO3-

20 mmol/L, urea 84mg/dl, creatinine 1.9mg/dl, serum glucose 680 mg/dL, serum

osmolality 334mOSM/kg, urine negative for ketones. ABGs: normal. WBC count

18,000/uL, CRP 120mg/L, ESR 70mm/h. What should the nurse expect when assessing this client?

• Fruity, acetone breath.
• Dry mucus membranes.
• Pupils narrow and irresponsive to light.
• Distended neck veins.

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Correct Answer: B

• The nurse observes that a client with a concussion following a car incident is

constantly blowing his nose. What is the best next action for the nurse to take?

• Instruct the client to stop blowing as this activity may increase intracranial pressure and

worsen the concussion.

• Offer the client a nasal decongestant.
• Measure the client's temperature and assess lung sounds.
• Look for signs of bruising around the client's eyes.

Correct Answer: D

• The nurse is analyzing the ECG of a 20 yr old previously healthy girl with an elevated

temperature caused by pneumonia. What should the nurse report to the HCP?

Correct Answer: The ECG demonstrates a sinus tachycardia

• A 78 yr old woman with a history of ischemic heart disease was experiencing

increasing shortness of breath. The following ECG record was obtained. What assessment findings are consistent with the ECG rhythm?Correct Answer: Pulse fast and irregularly irregular, increased jugular venous pressure

• The nurse is instructing a client with a newly implanted cardioverter defibrillator

(ICD). What statement indicates that teaching has been effective?

• "I should continue taking my anti-arrhythmic drugs."
• "I should avoid using the microwave or watching TV."
• "I should document every shock and take the list with me on my next cardiology visit."
• "I may feel it when my ICD fires, but it won't hurt."

Correct Answer: A

• An 18 year old girl with anorexia reports malaise, palpitations, dizziness spells and

lightheadedness. An ECG is obtained. After interpretation, what should the nurse do first to assist this client?

Correct Answer: Prepare an infusion of mag sulfate (torsades)

• When caring for a client with idiopathic myocarditis, what is a priority nursing

intervention?

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• Reducing congestion with diuretics and ACE inhibitors.
• Antibiotic administration to eliminate causative agent.
• Maintaining adequate fluid intake for hydration.
• Reducing fever with acetaminophen.

Correct Answer: A

• A client with type 2 diabetes mellitus is recovering from coronary angiography in the

intensive care unit (ICU). What finding would be of the most concern to the nurse?

• aPTT is 2 times the normal reference interval.
• Graft donor site is slightly red and swollen.
• Serum creatinine increased 1/4 from baseline.
• PaO2 is 80mmHg.

Correct Answer: C

• A client comes into the emergency department with a progressively worsening dull

upper abdominal pain for two days. The client has tachycardia, tachypnea, mild hypotension and an elevated body temperature. When completing the physical assessment, the nurse notes that Cullen sign is present. Based upon these findings, for which health problem should the nurse prepare care?

• Pericarditis.
• Acute pancreatitis.
• Appendicitis.
• Acute hepatitis.

Correct Answer: B

• A client who is intubated and on mechanical ventilation whispers to the nurse if she

can have a glass of water because her throat feels very dry. What should the nurse do?

• Explain to the client that a nothing-by-mouth status should be maintained.
• Get the client a glass of water.
• Increase humidity of the ventilated air.

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• Assess the client's cuff pressure.

Correct Answer: D

• The nurse is preparing a continuous heparin infusion for a client with a pulmonary

embolism. The prescribed dosage is 1300 U/hour. Heparin is available in a premixed solution of dextrose and water at a concentration of 25,000U/500mL. Within the next 24 hours the client should receive 31,200U of heparin. Calculate the pump setting in ml/hour. (Enter numeric value only).

Correct Answer: 26

• A client with a traumatic head injury and a Glasgow coma scale (GSC) of 7 is

intubated and being mechanically ventilated. The head of the bed is raised to 30 degrees and treatment with fentanyl, propofol and mannitol is initiated for increased intracranial pressure. What finding should cause the nurse the most concern at this time?

• Client has no response to painful stimuli.
• Client's blood pressure is 160/72 mmHg.
• Client's urinary output is 300 ml in the last hour.
• Client's blood glucose is 80 mg/dL.

Correct Answer: C

• While distributing medication, the nurse is stopped by a bedbound middle-aged

female client who reports a sudden onset of chest heaviness and difficulty breathing. Which intervention should the nurse implement first?

• Raise head of the bed.
• Measure vital signs.
• Call the physician.
• Quickly scan client's chart.

Correct Answer: A

• A client with ventricular tachycardia develops dyspnea, palpitations and

lightheadedness. Assessment reveals tachypnea, hypotension, pallor, diaphoresis, and jugular vein distention. Which nursing diagnosis should be included in the client's plan of care?