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Critical Care Exit Hesi(Questions & Answers)

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The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropria ... te action for the nurse to take? - Leave the cuff inflated and suction through the tracheostomy. A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? - Assess oxygen saturation levels. The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? - "Have you ever had chest pain?" The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? - Ask the client to describe the pain. Assessment: outcome priority; must validate that client is in pain before implementation A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? - Place the client on her left side with her legs flexed. Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? - Urinary output of 1,500 mL in 24 hours. Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? - 40 mg oral furosemide (Lasix) in the morning. Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension [Show More]

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