Critical Care HESI
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pt in ICU w/ asthma and a URI, experi-
1. Beta2-antagonist
encing severe bronchospasms and de-
velops status asthmaticus. Which pre-
Rationale
scription should the nurse administer
Beta2-antagonists and corticosteroids
first?
are used to treat status asthmaticus.
Beta2-antagonists facilitate smooth mus-
1. Beta2-antagonist
cle relaxation, while steroids decrease
2. Antihistamine
inflammation of the airways and enhance
3. Decongestant
the effects of beta2-antagonists.
4. IV antibiotics
The nurse is caring for a client admitted
to the critical care unit after sustaining in-
1. Positive Kehr sign
juries in a motor vehicle collision. Which
admission finding indicates a possible
Rationale
splenic rupture and should be reported
Signs of splenic rupture include referred
to the healthcare provider immediately?
pain to the left shoulder, which is known
as a positive Kehr sign. The nurse should
1. Positive Kehr sign
report it to the healthcare provider imme-
2. Positive Grey Turner sign
diately.
3. Pain at McBurney point
4. Rebound tenderness and rigidity.
IVP diltiazem
-calcium-channel blocker
-drug class
-afib/flutter, SVT
-indications
-normal HR
-therapeutic effect
MAP -((DBP x 2) + SBP))/3
-formula -70-100
-normal -low perfusion to body tissues (esp.
-what does a low MAP mean? brain)
An ICU client is extubated and placed on
1. Administer a PRN IV sedative.
40% oxygen via face mask. The nurse
finds the client confused and attempting
Rationale
to get out of bed. In shift report it was
The client is presenting with signs of al-
noted that client has not been sleeping.
tered sleep pattern in which a sedative
Oxygen saturation is 96%. Which inter-
will help the client rest. There are sev-
vention should the nurse implement?
eral modifiable factors that cause sleep
, Critical Care HESI
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1. Administer a PRN IV sedative.
disruption in critically ill clients such as
2. Change to partial rebreather mask.
noise, light, client care interactions, and
3. Limit visitors to immediate family.
medications.
4. Apply bilateral soft wrist restraints.
best lab to evaluate effectiveness of war-
INR: 2-3
farin and what is therapeutic
The nurse is caring for a client who was
admitted to the critical care unit with a
closed head injury sustained in a mo-
tor vehicle collision. Which finding in the
client's vital sign flowsheet indicates an
increase in intracranial pressure? 1. Heart rate 45 beats/minute and blood
pressure 180/80 mmHg.
1. Heart rate 45 beats/minute and blood
pressure 180/80 mmHg. Rationale
2. Heart rate 70 beats/minute and blood Cushing triad: brady w/ systolic HTN
pressure 140/100 mmHg.
3. Heart rate 90 beats/minute and blood
pressure 120/80 mmHg.
4. Heart rate 110 beats/minute and blood
pressure 80/40 mmHg.
pt is 12 hours PO for the removal of a
benign pituitary brain tumor. Pt is in a
drug-induced coma with NS 0.9% infus- 2. Prepare to administer desmopressin
ing at 125 mL/hr. HR is 90, BP is 100/60, (DDAVP).
and output is 250 mL of pale yellow urine
in the last 30 minutes. After reporting Rationale
these findings, which action should the Neurogenic diabetes insipidus (DI) can
nurse implement? occur when there is trauma to the brain
(esp. pituitary). The ADH deficiency oc-
1. Identify the underlying cause of this curs rapidly and results in polyuria w/ hy-
condition. povolemia. Treatment = administration of
2. Prepare to administer desmopressin exogenous ADH preparations, of which
(DDAVP). DDAVP is most commonly used. Fluid
3. Decrease the intravenous fluids to a output is carefully monitored and fluids
maintenance rate. are replaced every hour.
4. Replace fluid losses with D5W every
shift.
, Critical Care HESI
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pt w/ HHS is severely dehydrated. BP
78/46 mmHg, pulse 130, RR 22, MAP 0.9% NS bolus to overcome hypovolemic
58. Which IV solution should the nurse shock
expect to administer to this client?
The nurse is providing care for a new-
Minimize risk of bleeding
ly admitted client diagnosed with he-
1. Give stool softeners (& limit puncture
patic failure. Which interventions should
sites to skin)
the nurse perform while providing care?
SATA.
2. Measure abdominal girth (assess for
1. Give stool softeners.
ascites)
2. Measure abdominal girth.
3. Encourage a high protein diet.
4. Monitor BUN, LFTs, PT/PTT levels.
4. Monitor BUN, LFTs, PT/PTT levels.
5. Take glucometer readings every 2 to 4
LIMIT amount of protein intake
hours.
Partially compensated respiratory acido-
sis.
pH 7.32, PaCO2 50 mmHg, and HCO3
30
HCO3 is elevated to compensate for the
PaCO2.
Monitor temperature every 4 hours.
Rationale
The nurse is planning care for a client
Clients undergoing organ transplanta-
in the surgical intensive care who is one
tion receive immunosuppressant med-
day post liver transplant. Which interven-
ications, which increase the risk of in-
tion should the nurse include in the plan
fection. The plan of care should include
of care?
monitoring for signs of infection and ob-
taining the client's temperature every 4
hours around the clock.
A client with a history of chronic alco-
holism is admitted with pneumonia. The
nurse inserts two large bore IV catheters Magnesium 1.0
and starts an infusion of 0.9% sodium
chloride at 75 mL/hour and titrates the Rationale
client's oxygen to 60% by nonrebreather Normal magnesium level is 1.7 to 2.2
mask. The cardiac monitor displays sinus
tachycardia with multifocal premature
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