HESI RN EVOLVE Critical Care Practice Quiz/ Latest 2022:2023/ Guaranteed A+ Guide

HESI RN EVOLVE Critical Care Practice

Quiz

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?

A) "Your spouse's condition indicates irreversible damage."

B) "Let me contact the health care provider to answer your questions."

C) "Each person is different and we need to wait and see what happens."

D) "I need to initiate the volume expanders and warming blanket to stimulate a

response."

(ANS- B) let me contact the health care provider to answer your questions.

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?

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

B) Encourage the client to take deep breaths, cough, and expectorate.

C) Increase the flow rate of the humidified oxygen.

D) Suction the client's mouth and oropharynx thoroughly.

(ANS- A) Call a rapid response team for emergency airway management

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?

A) Push button when pain is first experienced instead of waiting until pain is

unbearable.

B) Family members or visitors can press the button when the client grimaces in

pain.

C) Press the button every 15 minutes even when pain is not present.

D) Delay pressing the button until the pain level is 8 on a scale of 1 to 10.

(ANS- A) Push button when pain is first experienced instead of waiting until pain

is unbareable

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?

A) Respiratory acidosis.

B) Respiratory alkalosis.

C) Metabolic acidosis.

D) Metabolic alkalosis.

(ANS- B) Respiratory alkalosis

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

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.)

A) Flailed ribs.

B) Fractured liver.

C) Ruptured spleen.

D) Cardiac tamponade.

E) Tension pneumothorax

(ANSB) Fractured liver

C) Ruptured spleen

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?

A) Metabolic panel with electrolytes.

B) Complete blood count.

C) Liver function test.

D) Blood culture.

(ANS- D) Blood culture

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?

A) An over-lying cranial bone flap is removed to allow swelling brain tissue to

expand.

B) The procedure uses a magnetic resonce imaging-guided laser ablation.

C) An opening into the skull is made to remove damage tissue.

D) A burr hole is drilled through the cranial bones to evacuate blood.

(ANS- A) An over-lying cranial bone flap is removed to allow swelling brain

tissue to expand

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?

A) Phosphate IV push.

B) Furosemide IV push.

C) Calcium gluconate IV push.

D) Diluted potassium IV push.

(ANS- C) Calcium gluconate IV push

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