Critical Care Practice hesi Correct and Verified Answers Graded A

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Critical Care Practice hesi Correct and Verified Answers Graded A

• The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically

ventilated. The ABG results are pH - 7.17; paCO2 - 70 mmHg; HCO3 - 30 mEq/liter. How should the nurse interpret this blood gas?

• Respiratory acidosis.
• Respiratory alkalosis.
• Metabolic acidosis.
• Metabolic alkalosis.

Correct Answer: A) Respiratory acidosis.

• The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated. The

ABG results are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the nurse interpret this blood gas?

• Fully compensated respiratory acidosis.
• Fully compensated respiratory alkalosis.
• Fully compensated metabolic acidosis.
• Fully compensated metabolic alkalosis.

Correct Answer: A) Fully compensated respiratory acidosis.

• A client's cardiac rhythm reveals peaked "T" waves, a widening "QRS" complex and the

flattening of "P" waves. Which medication should the nurse administer?

• Phosphate IV push.
• Furosemide IV push.
• Calcium gluconate IV push.
• Diluted potassium IV push.

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Correct Answer: C) Calcium gluconate IV push.

• The nurse is caring for a client admitted to the intensive care unit with a traumatic brain

injury from a motor vehicle collision. The client is experiencing increased intracranial pressure (ICP). The healthcare provider explains to the family that the client needs to go to surgery for decompressive craniectomy. Which information should the nurse explain to the client?

• An over-lying cranial bone flap is removed to allow swelling brain tissue to expand.
• The procedure uses a magnetic resonce imaging-guided laser ablation.
• An opening into the skull is made to remove damage tissue.
• A burr hole is drilled through the cranial bones to evacuate blood.

Correct Answer: A) An over-lying cranial bone flap is removed to allow swelling brain tissue to expand.

• A client reports to the nurse feeling achy and weak, being tired and coughing all the time,

frequent headaches and experiencing night sweats. The client's assessment is significant for crackles scattered throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse prepare to do first?

• Metabolic panel with electrolytes.
• Complete blood count.
• Liver function test.
• Blood culture.

Correct Answer: D) Blood culture.

• According to the paramedic's report, the victim of a motor vehicle collision was sitting in

the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic light when the vehicle was hit on the left side by another vehicle traveling at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L) side of thorax and body. The significant assessment findings include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is present in the (L) flank area and progresses towards the abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46

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mmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula. Which potential injuries should the triage nurse assess? (Select all that apply.)

• Flailed ribs.
• Fractured liver.
• Ruptured spleen.
• Cardiac tamponade.
• Tension pneumothorax

Correct Answer: B) Fractured liver, C) Ruptured spleen

• The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically

ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse interpret this blood gas?

• Respiratory acidosis.
• Respiratory alkalosis.
• Metabolic acidosis.
• Metabolic alkalosis.

Correct Answer: B) Respiratory alkalosis.

• An older client is admitted to the intensive care unit after a small bowel resection. The

postoperative prescriptions include a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide the client about the use of the PCA?

• Push button when pain is first experienced instead of waiting until pain is unbearable.
• Family members or visitors can press the button when the client grimaces in pain.
• Press the button every 15 minutes even when pain is not present.
• Delay pressing the button until the pain level is 8 on a scale of 1 to 10.

Correct Answer: A) Push button when pain is first experienced instead of waiting until pain is unbearable.

• The nurse is caring for a client who is recently extubated in the post anesthesia care unit

(PACU). The client has humidified oxygen per mask and suddenly develops stridor and respiratory difficulty. Which action should the nurse implement?

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• Call a rapid response team for emergency airway management.
• Encourage the client to take deep breaths, cough, and expectorate.
• Increase the flow rate of the humidified oxygen.
• Suction the client's mouth and oropharynx thoroughly.

Correct Answer: A) Call a rapid response team for emergency airway management.

• A client who has experienced trauma is admitted to the intensive care unit (ICU). The

nurse's initial assessment findings include a Glasgow Coma Scale score of (3), pupils fixed and dilated with an absence of corneal reflex, blood pressure of 80/30 mmHg, core temperature of 95.7°F (35.4° C). The client's spouse asks the nurse when the client will wake up. How should the nurse respond?

• "Your spouse's condition indicates irreversible damage."
• "Let me contact the health care provider to answer your questions."
• "Each person is different and we need to wait and see what happens."
• "I need to initiate the volume expanders and warming blanket to stimulate a response."

Correct Answer: B) "Let me contact the health care provider to answer your

questions."

• A client in the intensive care unit receives a STAT prescription for mannitol IV for

cerebral edema post closed head injury. Which action should the nurse implement when preparing to administer the medication?

• Use a filtered needle to draw up the medication and an in-line filter during infusion.
• Place atropine at bedside for use if the client has bradycardia during administration.
• Hyperventilate the client prior to administration to decrease intracranial pressure.
• Stop all sedation while mannitol is being administered per secondary infusion.

Correct Answer: A) Use a filtered needle to draw up the medication and an in-line filter during infusion.

• The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse

and no spontaneous respirations. The cardiac monitor displays a normal sinus rhythm.Which intervention should the nurse implement?

• Assess for signs of cardiac tamponade.