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Terms in this set (44)
Patient with peanut allergy presenting with respiratory and cardiac distress. What are the best nursing actions?
Establish patient airway
What action will prevent further infection (urosepsis) immunocompromised older patients with UTI?
Avoid invasive procedures → remove cath
For a patient in shock on Vasoactive medication the nurse should monitor which of the following?
Monitor mean arterial pressure (MAP)
MODS begin with failure of which organ?
Lungs → liver → GI → kidneys
50 y/o man presents with possible septic shock ax shows normal bp, increased hr, decreased bowel sounds and clammy skin. What stage of shock is he in?
Large volume of crystalloid fluids are used to treat a patient with hypovolemic shock, the nurse knows to monitor for
- Monitor for hypothermia
- Fluid resuscitation can cause hypothermia
- Nursing intervention: warm fluid prior to administration
Which of the following ax findings show hypovolemic shock in patient following a motor vehicle accident
Cool clammy skin
Low urine output
Early in the compensatory stage the patient skin will be _______ because blood is being shunted to heart and brain
Cool clammy skin
A patient is admitted for an MI, the heart is pumping an adequate amount of oxygen to tissues, what health problem might we want to assess for?
Chest pain and dysrhythmias
Patient with MODS, what nursing interventions to include in care plan
Communicating with family and patient
Cardiogenic shock may result in
Burn patients (acute to rehab phase) can't wait to reconstruct face so it looks like it used to, what is the best nursing response?
Tell them healing can take years and this is something they will address with the physician after their scars mature
Patient with 33% total surface area burn urine output have been steadily increasing 3 days following admission. WHat action should the nurse take?
No action, this is a normal response
Patient arrives in the ICU with full thickness burns over 25% of the body. Once cardiac and pulmonary issues have been stabilized, what's the next action?
Fluid status and resuscitation
What complication should the nurse be cognizant of when transferring a burn patient with burns on groins and circumstantial legs?
body weight (kg); 50% given in first eight hours; 50% gived in next 16 hours
- Example problem: 59 kg with 58% TBSA 2 mL of fluid per a kg. How much fluid do you give over an 8 hour period? Answer: 3422 in the first 8 hr
Patient presents with partial thickness burns on chest, arms and legs and reports smoke inhalation. The nurse knows the priority is
Airway management from smoke inhalation
Patient comes to the ER following an industrial accident. They weigh 155 pounds with full thickness burns over 40% of the body and are currently receiving fluid resuscitation. How does the nurse know fluid resuscitation is effective?
Increase urine output 40 mL an hour or more
Opioid overdose nursing intervention
- Watch for respiratory depression
- Elevate HOB at least 30 degrees
Patient admitted with diarrhea and vomiting is diagnosed with food poisoning. The nurse recognizes the following signs and symptoms of fluid and electrolyte imbalance
Patient swallowed a highly acidic toilet bowl cleaner 2 hours prior to admission, they were awake, what should the nurse give them?
Water or milk to dilute acid (do not want acid coming back up again)
Person at lunch is choking and coughing forcefully the nurse should
Encourage them to keep coughing
The nurse should perform what intervention if there is myoglobin in the patient's urine?
Increased fluids (beyond what is recommended) because myoglobin indicated muscle tissue destruction in the urine
Manifestations of carbon monoxide poisoning
- Appears to be intoxicated due to hypoxia
- Muscle weakness
Heat stroke assessment findings
- Anhidrosis: they can't sweat
- Elevated body temperature
What actions are completed in secondary survey in ED?
- Lab test
- Head to toe assessment
- Complete PMH
- Diagnostic test
- Insert IVs
A patient comes to the ER following a motor vehicle collision, their bp is 80/40, pulse 50, normal respiration rate with clear breath sounds, warm and dry skin. What type of shock should the nurse anticipate this patient is in?
Patient is reporting diarrhea, vomiting, and a history of adrenal insufficiency. What would the nurse instruct patient to increase intake of
What is the most important assessment for patient due with ascites
- Take patient weight
- Measure abdominal girth (hip to hip measure widest point of abdomen)
Previously very healthy individual were diagnosed with fulminant hepatic failure, what is the preferred treatment for this patient?
Patient with hepatic encephalopathy ax shows flapping tremors of hand. The nurse documents this as
The nurse knows the sterile bedside procedure to withdrawal fluid from patients abdomen is known as
Paracentesis (high fowlers and monitor BP)
Priority nursing intervention for patient following massive hemorrhage for cirrhosis of esophageal varices
Want to maintain airway
The nurse educates a patient on prednisone for several weeks to prevent adrenal insufficiency by
Tapering of med
Coworker bringing in patient after burn from high voltage electrical power line
Apply cervical collar
Clinical manifestations of hyperthyroidism include
- Restless, excitable, agitated, neck swelling, exophthalmos
- Nursing diagnosis for 30 year old with hyperthyroidism: impaired body image
Patient in resuscitative phase of burns expect the lab results to show
Features of cushing syndrome
What are late symptoms of hypothyroidism
Signs and symptoms to monitor for patient at risk for addisonian crisis
Rapid, weak pulse
Rule of 9 burns
Patient is in shock, getting internal nutrition to meet the body's nutritional needs. Why is this patient receiving enteral instead of parenteral feedings?
Promotes GI function, enteral goes right into the gut
A patient with suspected diabetes insipidus is scheduled for a fluid deprivation test. The nurse knows fluid deprivation tests require patients to withhold all fluids for 8-12 hours prior to testing so it is important to monitor closely?
Monitor blood pressure and heart rate
Examples of penetrating wounds
Stab wound or gunshot wound
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