Critical Care HESI Exam with verified answers graded A+
A client recovering from a percutaneous coronary intervention (PCI) after an acute myocardial infarction is being transferred from the PACU to the Cardiac ICU. Which assessment finding should the PACU nurse inform the healthcare provider of immediately?
a. onset of chest pain
b. need to apply pressure dressing
c. presence of occasional PVCs
d. absence of any urinary output during PACU stay - a. onset of chest pain
This suggests the onset of another MI and reocclusion of a vessel.
What is the preferred treatment of an acute MI within 12 hours of symptom
onset? - PCI; places a stent in the affected coronary artery
How often must a PCI pressure dressing site be assessed? - q30min for 4 hours
qh thereafter
Central Venous Pressure (CVP) - the pressure of blood in the thoracic vena cava,
near the right atrium of the heart; reflects the amount of blood returning to the
heart and the ability of the heart to pump the blood into the arterial system;
normal is 2-6 mmHg
Sensitivity of a pacemaker - pacing devices ability to detect what electrical activity
is being generated by the patient's heart to prevent any competition between the
hearts intrinsic activity
Contrast Induced Nephropathy (CIN) - A sudden deterioration in renal function
that is caused by intravascular administration of iodinated contrast medium;
typically seen with angiplasty/angiography
Signs of tension pneumothorax - 1. affected side will have decreased or absent lung sounds 2. cyanosis
3. Tracheal deviation (late sign)
4. distended neck veins
5. tachycardia, tachypnea
Pneumatic Antishock Garment - An inflatable device that covers the legs and abdomen; used to splint the lower extremities or pelvis, or to control bleeding in the lower extremities or pelvis. - used for intraperitoneal hemorrhage
What is the expected ABG of a pulmonary embolism? - Tachypnea and
tachycardia--> respiratory alkalosis
A client is brought to the emergency department following a motor vehicle accident. Initial assessment reveals that the client is unconscious with a blood pressure of 165/73 mmHg, HR 50 bpm, RR 8 and irregular, temperature of 103 F. What do you suspect is happening? - The findings reveal Cushing's Triad (hypertension with widening pulse pressure, bradycardia and bradypnea); this indicates increased ICP
Symptoms of Right Ventricular Hypertrophy - fatigue, swelling, weakness, chest
pain, SOB, dizziness
The nurse is caring for a client who is being weaned from mechanical ventilation.
Which assessment finding indicates that the client is ready to the the
endotracheal tube removed? - - pulse ox: 98% with a T piece
- evidence of reversal of the underlying cause of respiratory failure
-PEEP
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