HESI Critical Care Exit STUDY GUIDE 2020/2021

HESI Critical Care Exit STUDY GUIDE 2020/2021 Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Determine the following acid-base disorders Assess a 78 year old with L sided HF. Sym ...

HESI Critical Care Exit STUDY GUIDE 2020/2021 Nurse is reviewing client ECG and determines PR interval prolonged. Indicates Determine the following acid-base disorders Assess a 78 year old with L sided HF. Symptoms Caring for a burn patient with serum potassium of 4. Question which medication Patient admitted with deep 2nd degree burns of thighs, chest and arms covering 40% BSA. Fluid shift after burn so nurse expects Patient bedridden for 2 wks with following lab values: pH 7.37, PO2 90, PCO2 40, HCO3 25, hypoalbuminemia and hypocalcemia. Priority action Which age group should nurse assess first There has been a major disaster. Triage nurse should give which patient priority Move which patient to medical surgical unit One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do Carotid picture Someone with wound vac how to make sure it is effective Magnesium antidote Patient having trouble swallowing when wife gives drink of water Chest tube becomes disconnected Patient in ventricular fibrillation Know calcium levels….there was a question with calcium 5.0 and the answer was patient with hyperthyroidism taking inderal (propanalol) Chest tube volume 125 Heart sounds audio Patient on benzos ??? 4 patients-which one more concern 4 patients with conditions of concern-priority Patient on Heparin going for surgery in a.m.,-priority Patient with fever of 101-best nursing Dx Listening and hearing silence, then kortokoff sound what to do Patient with pancreatitis and elevated liver function-what expect of patient When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on right side only. Action Nurse called to a train derailment likely caused by terrorist bomb. Triage in order Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35. Which needs immediate communication to HCP Patient with dark, tarry stool Sign of GI bleed, pick NSAIDS Patient receiving Morphine in PCA pump Make sure the lock is on the machine Vasopressin Vasoconstrictor Patient comes in with Hx of MRSA put in isolation, get swabs Patient with thick secretions increase fluids Chronic renal failure-S/S Patient would get a black tag during a disaster if he/she exhibited which S/S Know your shocks S/S (hypovolemic, cardiogenic, etc-1 Q for each) 2 RNs must check blood products together before administration Glasgow Coma Scale <8 = coma Myasthenia crisis vs. cholinergic crisis Myasthenia-weakness with change in vitals (give more med) Cholinergic crisis-weakness with no change in vitals (reduce med) Diabetic ketoacidosis Fruity breath Hold Digoxin for HR <60 Stroke Tongue points toward side of lesion (paralysis), uvula deviates away from the side of the lesion (paralysis) Pulmonary air embolus prevention Trendelenburg (HOB down) and on left side to trap air in the right side of the heart Head trauma and seizures Maintain airway is primary concern Hypoventilation Acidosis (too much CO2) Hyperventilation Alkalosis (too little CO2) Cardiac enzymes that you need to know how often to assess after initial CVA Troponin (1 hour), CKMB (2-4 hrs), Myoglobin (1-4 hrs), LDH1 (12-24 hrs) MI treatment Morphine, oxygen, nitro, ASA (NO digoxin, betablockers or atropine for these patients) Ventilators Make sure the alarms are on (Check every 4 hours minimum), when suctioning give 100% O2 before and after and make no more than 3 passes-no longer than 15 seconds Have to put in order of consideration to be delivered Nasal cannula, simple face mask, nonrebreather mask, partial rebreather mask, venturi mask Early signs of cerebral hypoxia Restlessness and irritability Necessary for Blood Product infusions 18-19 gauge needle with filter tubing NS only run with blood within 30 minutes of hanging Check vitals before infusing, at 15 minutes, 30 minutes, then every hour, and directly after Checking blood before infusing 2 RNs Check order (expiration date, clots, color, air bubbles, leaks) patient, product, previous transfusion Hx Premedicate with Benadryl for previous rxn What does the PR interval represent Time required for the impulse to travel from atria through the AV node Isotonic solutions D5W NS Lactated ringers Tracheostomy Keep Kelly clamp and obturator at the bedside To assess CVA for hemorrhagic or ischemic CT scan first Heart conditions related to thrombus formation A-fib and A-flutter Aphasia, agraphia, slow, cautious, anxious, memory ok Left hemisphere lesion Cannot recognize faces, loss of depth perception, impulsive behavior, poor judgement, constant smile, loss of tonal hearing Right hemisphere lesion Most important indicator of increased ICP Change in LOC Spinal shock Complete loss of all reflexes If the U wave is most prominent what condition hypokalemia Burns First degree- epidermis {superficial} Second degree- epidermis and dermis {deep partial} Third degree- epidermis, dermis, and subQ {full thickness} Pic of patient and description of burns, need to decide what % burned [Rule of 9s- head and neck=9%, UE=9% each, LE=18% each, front trunk=18%, back trunk=18%] 5 Ps of neurovascular status (important with fractures) Pain, pallor, pulse, paresthesia, paralysis S/S of shock Increased pulse and decreased BP S/S of IICP Decreased pulse and increased BP with changes in LOC Suspected Post op bleeding if assess Frequent swallowing, vomiting blood, clearing of throat Primary medications given in ED for respiratory distress Bronchodilators [Sus-phrine (Epinephrine HCI) and Theophylline (Theo-dur)] ABG normals for the following: pH, pCO2, HCO3 pH: 7.35-7.45, pCO2: 34-45 mmHg, HCO3: 22-26 mEq/L Calculation of the heart rate using an EKG rhythm strip count the number of R-R intervals in the 30 large squares and multiply by 10 Intracranial hypertension from a traumatic brain injury is admitted to the trauma unit Elevated head of bed CPR-Arrange in other of priority Establish unresponsiveness Call for help Assess patent airway Assess pt carotid pulses Endometrial carcinoma receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator Wear a dosimeter film badge when in the client’s room 65-year-old female arrives in the ER with shortness of breath and chest pain, nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided The client would not be able to prove malpractice in court Deep vein thrombosis on heparin protocol based on a tPTT of 65 to 95 seconds. The current PTT result is 35 seconds Increase the rate of the heparin infusion Calculate the rate of this rhythm strip (It should be 90-100 depending on which set of 6 squares you use) A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol) Acetylcysteine (Mucomyst) The antidote for acetaminophen (Tylenol) is acetylcysteine (Mucomyst) For increase magnesium level Give calcium gluconate Patient admitted with a Dx of diabetic ketoacidosis (DKA) with scant urinary output, K+2.5 mEq/l, pH of 7.26, T 98ºF, HR 128 bpm, RR 36, and BP 90/52 Pottasium IV at 20 mEq/250 ml over 1 hour Irregular respiratory rate with periods of apnea lasting 10 to 15 seconds Apply supplemental O2 The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 85% Administer oxygen by face mask Doing CPR on intubated client with palpable pulse during 2-min cycle of chest compressions, absent breath sounds over left lung prepare for the endotracheal tube to be repositioned Unresponsive client who ingested an unknown number of meperidine (DEMOROL) 50mg tablets. Naloxone (NARCAN) 0.4mg IV is administered, and the client is now responding to verbal stimuli. Which finding in the next hour requires immediate action by the nurse Difficulty in arousing Patient in the MICU. What problem is a client probably experiencing who has an easily obliterated radial pulse and below-normal pressures, (BP), (CVP), (PAP), and pulmonary under pressure Hypovolemic shock PRI interval depolarization and repolarization Which is the highest for carcinogenic shock traumatic amputation from the groin down (there one of the choice a pt w/ gunshot wound to the chest and abdomen) *HESI HINT: if Cardiogenic shock exits in the presence of pulmonary edema (ex. from pump failure), position pt to reduce venous return (high fowler’s w/ legs down) in order to reduce further venous return to the left ventricle Patient with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick-release tie Reposition the restraints ties, securing them to the bed frame Nursing home patient admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m.and the nurse is running behind schedule (Zosyn) over 30 minutes q8 hours first During a family baseball game, an adult male is hot on the head with a bat, and he is suspected of sustaining an epidural bleed “Was your husband knocked out by the blow” CPR for a pregnant lady Heimlich w/ chest compression *HESI HINT: At 20wks gestation & beyond, the gravid uterus should be shifted to the left by placing the women in a 15-30 degree angled, left lateral position or by using a wedge under her right side to tilt her to her left Patient has received 250 ml of 0.9% normal saline through the IV line in the last hour and is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. Decrease the saline to keep-open rate In EKG reading which complex represents depolarization of the ventricles QRS complex The risk for metabolic shock syndrome Toxic Shock Syndrome 23 year-old male brought to the ER by a group of fraternity brothers after a hazing event at the university. Blood alcohol level (BAL) of 3.8 and a Glasgow Coma Scale of 3 Initiate IV access using Lactated Ringer’s solution 1000ml with thiamine 100mg The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane A yellow disaster tag means critical injuries and require immediate intervention Electrical burn pt put him in a cardiac telemetry monitor A pt on a trachea/endotrach with gurgling sound always pick suctioning Metabolic syndrome high cholesterol & high BP (cardiac strip) IV Line Flush line before and after compatible IV solution Priority pt Ruptured spleen life threatening Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual) Pleaurvac, know how to set vac at 850 39 to 48 Glucose Notify healthcare provider of client’s status Disseminated intravascular coagulation (DIC) best test to diagnose, D-Dimer Septic shock-best class of medicine to give are Anti infectives A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye Have the parent take the child for emergency help Patient admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The healthcare provider determines the client is in acute renal failure (ARF) Hourly neurological assessments 14-year-old male arrives at the ER in status epilepticus. He was diagnosed with a seizure disorder in childhood Acute withdrawal from anticonvulsant medication Most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter Shortness of breath Patient with Hx of chronic atrial fibrillation Be sure to take the prescribed daily aspirin Most important for the nurse to use an IV pump and/or Buretrol when initiating IV therapy after which surgical procedure Craniotomy Acute renal failure with a serum potassium of 7.5mEq/L. based on this finding Administer a retention enema of Kayexalate A client admitted to the hospital is suspected of having meningitis Lumbar puncture infant admitted to the NICU is tachypneic, tachycardic, and has bounding brachial pulses Monitor for congestive heart failure Feedings for low albumin Nepro, Ensure or TPN if pt is NPO BNP 500, prescribed diuretic indicates HF Acute Pancreatitis withhold food and fluid intake Mechanical life support Know equipment used Pulmonary Edema Fluid leaks out of the small blood vessels into the air sacs of the lungs CVP via PA port Cover the cap w/ tape and label the port as being obstructed (While flushing the proximal port triple lumen central venous cath w/heparin lock meets resistance) In EKG reading which wave represents depolarization of the atrium P wave Math IV mg/kg/minute-dopamine Allen's test test for occlusion of the radial or ulnar artery, in which one of these arteries is compressed after blood has been forced out of the hand by clenching it into a fist; failure of the blood to diffuse into the hand when opened indicates that the artery not compressed is occluded Pacemaker-Failure to sense Fails to sense patient’s own intrinsic rhythm and generates a pacer spike (when output is too low resulting in failure to depolarize the ventricle results in Bradycardia **Use Atropine) DIC most often seen in leukemia and in adenocarcinomas of the lung, pancreas, stomach, and prostate Diabetes -acute confusion Give 4 oz. apple juice Priority-compartment syndrome Surgery needed. Emergency! Fasciotomy may be necessary Head injury major desired outcome for rehabilitation after head injury is to maximize the patient's ability to return to his or her highest level of functioning Pulmonary embolism-S&S Dyspnea, sudden onset Pleuritic chest pain Apprehension, restlessness Feeling of impending doom Cough Hemoptysis Tachypnea Crackles Pleural friction rub Tachycardia S3 or S4 heart sound Diaphoresis Fever, low-grade Petechiae over chest and axillae Decreased arterial oxygen saturation (Sao2) Subcutaneous emphysema is felt as a crackling sensation beneath the fingertips MODS (Multiple Organ Dysfunction Syndrome) after an Abdominal Gunshot wound Apply pressure & keep flat Ventilator-ET to check placement listen to breath sounds Anaphylactic-bracelet patient should wear bracelet stating he is allergic to certain medication Shock –hemorrhagic give isotonic 0 .9% NS or LR Heat stroke increase IV fluids to 200ml/hr, apply cool packs to persons body CPR-absent lung sounds ventilate with two mouth to mouth breaths over 1 second and make the chest rise then palpate for pulse, if no pulse do CPR Myxedema coma S&S hypothermia, bradycardia, hypotension, res. Acidosis. Happens when patient suddenly stops taking thyroid med. Give thyroid replacement meds, Airway must be kept open Burn airway, administer LR, premedicate with sulfamylon CVA – Anosognosia lack of awareness or a denial of a neurological defect paralysis Patient in cardiac arrest and monitor shows pulseless VT Defibrillation with 200 to 360 joules Identify the waveforms found in a normal EKG P wave, QRS complex, T wave, ST segment, PR interval 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