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Hesi Rn Critical Care Ngn Proctored Exam
Total Questions : 59
Showing 10 questions, Sign in for moreA client receives a prescription for dopamine 200 mg/500 mL IV to be infused over 45 minutes. The nurse should program the infusion pump to deliver how many mL/hr? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Explanation
Calculation:
- Identify the total volume and infusion time
Total Volume: 500 mL
Infusion Time: 45 minutes (0.75 hours)
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 500 ÷ 0.75
Infusion Rate = 666.67 mL/hr
- Round to the nearest whole number
= 667 mL/hr
A 65-year-old male client is brought to the emergency department (ED) by his wife. Client says he felt extremely fatigued, had dyspnea when lying down or with exertion, and felt heart palpitations. He is reporting chest pain at 8 on a 0 to 10 scale that is described as sharp and uncomfortable. Neck vein distention and 3+ pitting edema in his feet and ankles are noted. Auscultation reveals a high pitched holosystolic murmur at the heart apex with radiation to the left axilla and an S heart sound. Peripheral pulses are bounding. He has a medical history of mitral valve prolapse and high cholesterol.
Home medications
- Simvastatin 10 mg PO in the evening
The client is placed in an emergency department (ED) room and connected to monitors. A portable chest x-ray is completed An 18 gauge peripheral IV (PIV) access device is placed in his right antecubital, and blood is drawn for the laboratory tests. Oxygen is placed on the client at 2 L/minute via nasal cannula.
1815
A 12-lead electrocardiogram (ECG) is performed showing atrial fibrillation (A-fib) with rapid ventricular response (RVR) 136 beats/minute. Started the IV fluid bolus. The head of bed is placed at 45 degrees to facilitate breathing.
1830
Performed a physical assessment and rechecked vital signs
Assessment
- Neurological: Fatigued. Disoriented to time. Appears restless.
- Cardiovascular: Irregular heartbeat auscultated and electrocardiogram showing atrial fibrillation (A-fib) with rapid ventricular response (RVR) 136 beats/minute High pitched holosystolic murmur at the heart apex with radiation to the left axilla. Weak peripheral pulses noted with cool and clammy skin. 2+ pitting edema in extremities. No edema. Chest pain reported 8 on a 0 to 10 scale described as sharp and uncomfortable.
- Respiratory: Tachypnea.
- Musculoskeletal: Weakness noted.
- Gastrointestinal: Hypoactive bowel sounds in all quadrants.
- Genitourinary: No urine output. The client's wife reports he was incontinent at 1000 this morning.
1845
Client is in his room and appears to have no major improvements. The fluid bolus has completed, and the continuous infusion is started. Continues to report pain, notified the healthcare provider (HCP). Laboratory results are reviewed.
1840
Complete Blood Count
|
Laboratory Test |
Results |
Reference Range |
|
White blood cells |
14,000/mm3 (14 x 10^9/L) |
5,000 to 10,000/mm3 (5 to 10 x 10^9/ L) |
|
Hemoglobin |
13 g/dL (130 g/L) |
14 to 18 g/dL (140 to 180 g/L) |
|
Hematocrit |
44% (0.44 volume fraction) |
42% to 52% (0.42 to 0.52 volume fraction) |
|
Platelets |
440,000/mm3 (440 x 10^9/L) |
150,000 to 400,000/mm3 (150 to 400 x 10^9/L) |
Cardiac Markers
|
Laboratory Test |
Results |
Reference Range |
|
Troponin T |
0.3 ng/mL (0.3 μg/L) |
less than 0.1 ng/mL (less than 0.1 μg/L) |
|
Troponin I |
0.09 ng/ml (0.09 μg/L) |
less than 0.03 ng/mL (less than 0.03 μg/L) |
|
Creatine kinase MB |
8% |
0 to 6% |
|
Laboratory Test |
Results |
Reference Range |
|
Erythrocyte sedimentation rate |
44 mm/hr |
Less than or equal to 15 mm/hr |
1800
Vital signs
- Temperature: 98.6° F (37° C) orally
- Heart rate: 136 beats/minute
- Respirations: 28 breaths/minute
- Blood pressure: 90/42 mm Hg
- Oxygen saturation: 84% on room air
- Height: 5 ft 9 in (175 cm)
- Weight: 220 lb (100 kg)
- Pain: rated 8 on a 0 to 10 scale, sharp and uncomfortable in the chest
1805
Vital signs
- Oxygen saturation 93% on 2 L/minute nasal cannula
1800
Chest x-ray, STAT
Echocardiogram (ECHO), STAT
Continuous electrocardiogram (ECG) monitoring
Titrate oxygen 1 to 5 L/minute via nasal cannula to maintain oxygen saturations of 92% or higher
Insert peripheral IV (PIV) access device
Infuse 0.9% sodium chloride 300 mL IV bolus over 30 minutes, then infuse 0.9% sodium chloride continuous IV infusion at 125 mL/hour
Complete blood count (CBC), complete metabolic panel (CMP), and cardiac markers STAT
1845
Consult for insertion of arterial line
Consult for placement of a central venous catheter and monitor central venous oxygen saturation (Scvo2) and venous oxygen saturation (Svo2)
Insert indwelling urinary catheter for strict input and output monitoring
Milrinone bolus of 50 mcg/kg over 10 minutes IV piggyback (IVPB), then infuse at 0.375 mcg/kg/min IV infusion
Morphine 2 mg IV push (IVP) now for pain, then every hour PRN for pain greater than 3 on a 0 to 10 scale
Dopamine 3 mcg/kg/min diluted in 500 mL of 0.9% sodium chloride via IV infusion
Prepare client for mitral valve replacement surgery
1845
Two dimensional transthoracic echocardiography: The apical four chamber view reveals the left ventricle is dilated and the mitral valve coaptation point displaced. Severe mitral regurgitation and mitral prolapse.
Chest x-ray: Increased cardiac shadow, indicating left ventricular and left atrial enlargement.
Patient Data
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale:
• Cardiogenic shock: The client presents with hypotension, tachycardia, altered mental status, cool clammy skin, oliguria, and severe hypoxia, all of which indicate inadequate tissue perfusion. Echocardiography confirms severe mitral regurgitation with ventricular dilation, leading to poor forward cardiac output. Elevated cardiac markers and atrial fibrillation with rapid ventricular response further compromise cardiac function.
• Heart failure (HF): Although the client has signs of heart failure, including dyspnea, edema, and crackles, the presence of hypotension and end-organ hypoperfusion indicates progression beyond simple heart failure. Cardiogenic shock represents a severe complication of heart failure with systemic consequences. The unstable vital signs and altered mental status support shock physiology. Therefore, heart failure alone does not fully explain the severity of findings.
• Myocardial infarction (MI): Elevated troponins suggest myocardial injury but do not confirm an acute MI as the primary condition. The clinical picture is dominated by pump failure rather than coronary occlusion. Severe mitral regurgitation and ventricular dilation explain the cardiogenic shock more directly. MI may be contributory but is not the primary condition.
• Hypertrophic cardiomyopathy (HCM): HCM typically presents with diastolic dysfunction, preserved systolic function, and a systolic murmur that increases with decreased preload. This client instead shows ventricular dilation and severe mitral regurgitation on echocardiogram. The hemodynamic collapse and volume overload are inconsistent with HCM pathology.
• Administer dopamine: Dopamine at low to moderate doses supports cardiac output by improving myocardial contractility and maintaining blood pressure. The client’s hypotension and signs of poor perfusion make vasoactive support essential. Dopamine helps preserve end-organ perfusion while definitive surgical intervention is planned.
• Administer morphine: Morphine reduces preload and afterload by promoting venodilation, which decreases pulmonary congestion and myocardial oxygen demand. It also relieves severe chest pain and anxiety, both of which increase sympathetic stimulation and worsen cardiac workload. In cardiogenic shock with pulmonary congestion, morphine can improve breathing comfort. Pain control also supports hemodynamic stability.
• Place client on reverse isolation: Reverse isolation is used to protect immunocompromised clients, not those experiencing cardiogenic shock. There is no evidence of neutropenia or infection risk requiring isolation. This intervention would not address perfusion or oxygenation issues. Priority interventions should focus on hemodynamic support.
• Insert nasogastric tube (NGT): An NGT is not indicated in cardiogenic shock unless there is bowel obstruction or severe gastric distention. The client’s hypoactive bowel sounds reflect hypoperfusion, not a gastrointestinal obstruction. Inserting an NGT would not improve cardiac output or oxygenation.
• Transfer client to a cardiac specialty facility: While advanced care is needed, the client is already receiving specialty-level interventions including invasive monitoring and surgical preparation. Immediate stabilization takes priority over transfer logistics. The focus is maintaining perfusion while preparing for mitral valve replacement.
• Urinary output: Urinary output is a sensitive indicator of renal perfusion and overall cardiac output. The client has had no urine output, signaling severe hypoperfusion. Monitoring output allows the nurse to evaluate response to inotropes and fluid management. Improvement suggests better tissue perfusion and stabilization.
• Respiratory rate: An elevated respiratory rate reflects hypoxia and pulmonary congestion caused by left-sided cardiac failure. Monitoring respirations helps assess oxygenation status and response to interventions such as morphine and oxygen therapy. Decreasing tachypnea indicates improved pulmonary circulation and gas exchange.
• Sulfate sensitivity: There is no indication of medication allergy or hypersensitivity reactions. Monitoring sulfate sensitivity is unrelated to the client’s cardiovascular instability. This parameter does not provide information about cardiac output or perfusion.
• Neck vein distention: Neck vein distention reflects volume overload and elevated central venous pressure but does not adequately assess improvement in shock state. While present, it is less useful for tracking response to therapy than urine output or respiratory status. Shock management focuses on perfusion rather than static volume indicators.
• Angioedema: Angioedema is associated with allergic reactions and airway compromise, which are not evident in this case. There is no facial swelling or airway involvement reported. Monitoring for angioedema would not help assess cardiogenic shock progression.
The client's 12-lead electrocardiogram (ECG) waveform indicates the rhythm has changed from 1st degree to 3rd degree atrioventricular (AV) heart block. Which intervention should the nurse implement?
After seven days of mechanical ventilation, an older adult client is extubated and is now receiving 50% oxygen via face mask. The client has become anxious and is beginning to hyperventilate. Which intervention is most important for the nurse to implement?
The healthcare provider (HCP) prescribes lidocaine 4 mg/minute IV for a client experiencing premature ventricular contractions (PVCS). The IV bag contains lidocaine 1 gram in 500 mL DW. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only)
Explanation
Calculation:
- Identify the prescribed rate and IV concentration
Prescribed Rate: 4 mg/min
IV Concentration: 1 gram in 500 mL
1 gram = 1,000 mg
- Convert the prescribed rate to mg/hr
4 mg/min × 60 min = 240 mg/hr
- Calculate the infusion rate in mL/hr
Infusion Rate (mL/hr) = (Prescribed Dose per hour ÷ Total Dose in Bag) × Total Volume
Infusion Rate = (240 ÷ 1,000) × 500
Infusion Rate = 0.24 × 500
Infusion Rate = 120 mL/hr
- Regulate Insulin drip based on blood sugar as follows
- Blood Glucose Range and Drip Rate >200 Increase drip rate by 2 units/hr
- 150-199 Increase drip rate by 1 unit/hr
- 100-149 Decrease drip rate by 50% or by 2 units (whichever is smaller decrease)
- <100 Stop Insulin drip. Check blood glucose hourly until blood glucose >100, then resume drip at 1 unit/hr and regulate as above
A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?
Reference Range:
- Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
The nurse is preparing to start an IV infusion of 1,000 mL of 0.9% sodium chloride with 30 mEq of potassium chloride for a client with diabetic ketoacidosis (DKA). Before implementing the prescription, which assessment finding is most important for the nurse to obtain?
The rapid response team transfers a client with sepsis to the intensive care unit (ICU). The client's white blood cell count is 28,000/mm3 (28 x 10^9/L). Which intervention should the nurse implement first?
Reference Range:
- White blood cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10^9/L)]
A client is receiving cardiopulmonary resuscitation (CPR). After asystole is confirmed in two leads and sending for the code cart, which IV medication should be administered?
A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?
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