CRITICAL CARE HESI PRACTICE {ALREADY GRADED A+ } NEWEST VERSION TESTBANK

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CRITICAL CARE HESI PRACTICE {ALREADY

GRADED A+ } NEWEST VERSION

TESTBANK

• The nurse is caring for a client with burns and reviews the client's laboratory results:

blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings?

• Azotemia
• Hypokalemia
• Metabolic alkalosis
• Respiratory alkalosis

Correct Answer: a

• A nurse is caring for a client with severe burns. The nurse determines that this client

is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion?

• Decreased rate of glomerular filtration
• Excessive blood loss through the burned tissues
• Plasma proteins moving out of the intravascular compartment
• Sodium retention occurring as a result of the aldosterone mechanism

Correct Answer: c

• A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping

for breath, and reports right-sided chest pain. What should the nurse do first?

• Obtain vital signs
• Initiate a cardiac arrest code

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• Administer oxygen using a face mask
• Encourage the use of an incentive spirometer

Correct Answer: c

• The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the

priority concern of the nurse when caring for this client?

• Fluid volume
• Skin integrity
• Physical mobility
• Urinary elimination

Correct Answer: b

• A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart

rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm?

• Normal sinus rhythm
• Sinus tachycardia
• Sinus bradycardia
• Sinus arrhythmia

Correct Answer: a

• During the first 48 hours after a client has sustained a thermal injury, which

conditions should the nurse assess for?

• Hypokalemia and hyponatremia
• Hyperkalemia and hyponatremia
• Hypokalemia and hypernatremia
• Hyperkalemia and hypernatremia

Correct Answer: b

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• A client is admitted to the hospital with partial- and full-thickness burns of the chest

and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern?

• Loss of skin integrity caused by the burns
• Potential infection as a result of the burn injury
• Inadequate gas exchange caused by smoke inhalation
• Decreased fluid volume because of the depth of the burns

Correct Answer: c

• 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

Correct Answer: d

• A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse

rushes to the scene and determines that the person is in cardiopulmonary arrest.What should the nurse do first?

• Feel for a pulse
• Begin chest compressions
• Leave to call for assistance
• Perform the abdominal thrust maneuver

Correct Answer: b

• The nurse is providing postprocedure care to a client who had a cardiac

catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take?

• Notify the primary healthcare provider immediately

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• Apply a warm, moist compress to the incision site
• Increase the intravenous fluid rate by 20 mL/hr
• Monitor vital signs more frequently

Correct Answer: a

• A nurse is caring for a client who experienced serious burns in a fire. Which

relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns?

• Equal
• Unrelated
• Inversely related
• Directly proportional

Correct Answer: d

• A burn client is receiving the open method for wound treatment. Which

information will the nurse explain to the client?

• Bathing will not be permitted.
• Dressings will be changed daily.
• Personal protective equipment will be worn by staff.
• Room temperature will be kept below 72° F (22.2° C).

Correct Answer: c

• A client presents to the emergency department with weakness and dizziness. The

blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3- pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client?

• Deficient fluid volume
• Impaired skin integrity
• Inadequate nutritional intake
• Decreased participation in activities

Correct Answer: a