HESI Critical Care 2019 TEST BANK RN

1). Pt has a long history of smoking. Pt comes in with sob. These are the ABG’s: pH 7.25, PCO2 50, anD HCO3 24. What does the patient have?  Resp. Acidosis *Remember: If the CO2 is high it will always be resp. acidosis 2). Female comes in the ED and says that her “heart is pounding outside of her chest. Client is in SVT. What is the nursing intervention?  Coach client in relaxation and deep breathing. 3). This is an insulin PROTOCOL question. You will be given a protocol that you need to follow by the MD. The pt insulin is infused at 5 units/hr and her current glucose reading is 165. What should you do?  Increase drip by 1 unit/hour 4). Calculate question. The number will be 1,500,000 IU, in 500mL of 0.9% NS.  33 5). DKA math question  1,000mL NS with 30 Meq of Sodium 6). Older client comes in with CAP and SpO2 89%. What is the priority intervention?  Assist client with turning, coughing, and deep breathing 7). Pt received an ETT 7 days ago and is currently on 50% O2. The pt is currently anxious and hyperventilating. What is the priority intervention?  Auscultate lungs 8). Client has not been taking cortisone for either 2 weeks or 2 months and husband brings her into the ED. Husband states that she has not been feeling well and that she needed help getting ready today. (Patient has SIAH). What should you do?  Initiate fall precautions *Remember that SIAH causes seizures so you have to put the client on fall precaution 9). UAP is coming to assist a nurse in a situation where the pt is having SVT and the nurse has to prepare for cardioversion. What task can the UAP do?  Bring Resuscitation cart to the bedside 10). A pt has a cardioversion due to uncontrolled A Fib. What vital shows that the cardioversion was successful?  Normal sinus rhythm with hr 84 11). Pt has ortho surgery and 12 hrs after the surgery the patient is anxious and sob. What is the nursing intervention?  Position client on the left side 12). The pt is receiving dopamine. What do you have to monitor for while on this drug?  Monitor urinary output 13). During the insertion of a swan gans, what should the nurse do?  Monitor for dysrhythmias 14). Which of these vital signs are contraindicative of ICP?  PaCO2 of 55 *Remember that normal PaCo2 should be between 35-45. When it increased, it will cause more ICP. 15). There is a question about SIAH and normal lab values that would be associated with this disease.  HYPERkalimemia and HYPOnatremia 16). A pt has a Glasgow coma scale of 14. What should the nurse do?  Document the findings 17). When caring for a client on a ventilator which finding shows the airway is open?  Bilateral breath sounds can be auscultated 18). Pt is in the ICU after a colon resection. The vital signs are: 135hr, temp 103, and BP of 88/65 and urine output of 10mL/ hr. What should the nurse do?  Give a 500mL IV bolus challenge. 19). There will be another question just like 18. The scenario will be different but the BP will be very low as well.  The answer will be the same as 18 but it will not say challenge. 20). A client has syncopal episodes due to 3rd degree block. The patient receives a transcutaneous pacemaker. The nurse observes that there are several episodes the pacemaker fails to sense. What should the nurse do?  Increase the sensitivity 21). Which of these drugs are the strongest or most effective vasodilators?  Lidocaine 22). There will be another math question. It’s mcg to mg. 4mcg/kg and client weighs 165 lbs.