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Complex MedSug Final

Terms in this set (49)

Which finding indicates that the AV fistula is patent?
Palpation of a thrill
Which lab result would indicate epoetin alfa is effective?
HCT 33%
Four hours post TURP, the nurse takes the pt VS and empties the foley bag. Which finding needs to be reported to the PCP
BP 100/50, HR 130 BPM
Which pt is the nurse's priority?
Pt w/ WBC of 14,000 and temp of 101.5
The RN is making assignments for 3 CNAs and 1 LPN. Which pt should be assigned to the LPN?
A pt requiring abd wound irrigation and dressing change Q3H
A pt is on a heparin gtt to treat DVT. His recent aPTT is 65 seconds. The nurse anticipates which action is needed?
Leave the rate as is, Therapeutic range of aPTT is 65-85 seconds
Which BUN level reflects normal hydration
15, normal BUN range 7 to 20 mg/dL
The pt has an elevated ST segment in chest leads V1, V2, and V3. Where does the nurse suspect the MI?
Anterior
The patient underwent pericardiocentesis for cardiac tamponade. Which observation would indicate it was effective?
A rise in BP
Signs and Symptoms of cardiac tamponade
Muffled heart sounds, Pt reports dyspnea, Jugular venous distention
Which is an early symptom of benign prostatic hyperplasia?
Decreased force in the stream of urine
Which lab would the nurse MOST LIKELY expect to see in a pt with CKD?
Elevated creatinine levels
The nurse caring for a patient with a history of autonomic dysreflexia should..
Turn and reposition the client at least every 2 hours.
Which of the following labs would the nurse expect to find decreased in a patient with cirrhosis.
Albumin
Which intervention can be found in the end of life delirium care plan.
Give gentle massage
Which of the following labs is most likely to be decreased with ESRD?
Sodium
The nurse should report which of the following symptom prior to initiating thrombolytic therapy to a patient with a PE
BP of 198/110, High BP increases risk of cerebral hemorrhage
Successful fluid resuscitation is evaluated by.
Adequate urine output, Intact LOC, Palpable peripheral pulses
The Parkland Formula
RL 4mL/kg/%TSBA burn
Causes of metabolic acidosis
Acute Kidney Injury, DKA, Severe diarrhea
Analyze this blood gas: pH of 7.5 PACO2 is 30, HCO3 is 20.
Respiratory alkalosis, compensated
Preventing ventilator associated pneumonia (VAP)
Inline suctioning (sterile), oral care w/ chlorhexidine solution, decrease gastric residual, HOB 30 degrees, PPIs
High pressure alarm on ventilator
Air is unable to expand the chest inside the system. (patient coughing, decreased tidal vol, biting on the tube, need suctionioning, kinking, "fighting" ventilator)
Low pressure leak on ventilator
Disconnected
Which of the following labs is consistent with sepsis?
WBC >12,000 or <4,000
A patient complains of right upper quadrant pain, elevated temp, flatulence, floating. which GI disorder should the nurse consider?
Diverticulitis
In case of fire, RACE
R - rescue & remove all clients in immediate danger
A - activate alarm
C - confine fire by closing doors & windows
E - extinguish
Best low sodium diet for your patient.
no cheese, no canned anything, no deli meat
Which hemodynamic monitoring line will measure the right atrial pressure?
CVP line
CVP line
Sits in the right Atrium and it measures pressures on the right side of the heart.
Arterial Line
Measures arterial pressure it's usually in your radial artery, it can be other places.
Pulmonary artery pressure (swan gnaz)
Measures the pressure on the left side of the heart.
ACLS treatment for Unstable Bradycardia
Administration of atropine
(TPN) total parenteral nutrition
Requires a filter, infused through a large vessel (central line), monitor blood glucose levels q4h while on TPN due to high concentration of dextrose, wean slowly to prevent rebound hypoglycemia
Which of the following labs confirms HIV positivity?
Western Blot
CD4 Count
normal 500-1500
<500 HIV
<200 AIDS
The p/t with rule out pancreatitis is made NPO. Which statement indicates he understands why he's NPO?
Food will stimulate the secretion of amylase and lipase, starts autodigestion of pancreas
The patient is scheduled for chemotherapy. Which prelabs will prevent her from receiving chemo today?
WBC 1,500
Four patients arrived in the ED. Which is the highest priority?
Unequal chest expansion
The nurse knows the patient with HIV and a CD4 count of 200, needs further instruction when he states:
My CD4 count is adequate to fight off most infections
Which medication according to ACLS should you give a patient with this rhythm?
Epinephrine
The patient has crackles bilateral lung fields. Which cardiac disorder should the nurse consider?
Left sided heart failure
A patient has thrombocytopenia which of the following interventions is appropriate?
Assess for bruising (due to low platelets)
When do we see changes of troponin levels?
3 hours
A burn involving the epidermis, dermis, subcutaneous fat, muscle, and bone is classified as:
Full thickness
What are the nursing diagnosis for a patient with hypovolemic shock from hemorrhaging?
Altered tissue perfusion, decreased cardiac output
What are the signs of multiple organ dysfunction?
Diarrhea, oliguria, high gastric residual, ascites, low O2 sat
Treatment for pulseless tachycardia
Defibrillation, epinephrine, CPR
Patient is admitted for severe bradycardia from a 3rd degree heart block and BP 80/60. What should you do first?
Atropine
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