Critical Care Exit Hesi 2.LATEST-ALL ANSWERS VERIFIED 100%

Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes
telemetry pattern shows second degree heart block with Ventricular rate of 50. Action
Hold scheduled dose and notify HCP of telemetry pattern
Nurse is reviewing client ECG and determines PR interval prolonged. Indicates
Increased conduction time from the SA node to the AV junction
When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on
right side only. Action
Reposition the depth of the ET tube
Nurse called to a train derailment likely caused by terrorist bomb. Triage in order
Middle-aged man wandering around
Woman sitting on ground with blanket
Crying child held by another passenger
Mother and father just arrived on scene
Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35.
Which needs immediate communication to HCP
Drowsiness and diff in arousing
Assess a 78 year old with L sided HF. Symptoms
Dyspnea, cough, fatigue
Caring for a burn patient with serum potassium of 4. Question which medication
Potassium
Patient admitted with deep 2nd degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after
burn so nurse expects
Decreased cardiac output
Patient bedridden for 2 wks with following lab values: pH 7.37, PO2 90, PCO2 40, HCO3 25,
hypoalbuminemia and hypocalcemia. Priority action
Turn patient side to side q2h
Which age group should nurse assess first
40 year old with sickle cell crisis
There has been a major disaster. Triage nurse should give which patient priority
Cut over eye
Move which patient to medical surgical unit
Patient with ABNL liver levels
One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do
Take patient to ICU and arrange for respiratory patient to stay in PACU