Pneumothorax
This nurse will assess the lungs and find this type of breath sounds with a pneumothorax.
What is absent breath sounds?
The nurse knows that the initial trauma survey includes this.
What is airway, breathing, circulation, disability, and exposure? ABCDE
The nurse knows that hypovolemic shock can occur from one of these two main causes.
What is hemorrhagic (bleeding) or non-hemorrhagic (fluid loss such as dehydration)?
The nurse will look at these lab value results to determine if there is kidney failure.
What is BUN (urea), Creatinine, and GFR (glomerular filtration rate)?
The nurse knows that these medications are commonly used to treat heart failure.
What are ACE inhibitors and loop diuretics?
The nurse will anticipate this procedure when a patient has a pneumothorax.
What is chest tube placement?
The nurse knows several examples of traumatic injuries which may not be visible such as these.
What is internal bleeding, rib fractures, and internal organ damage?
The nurse would look for these lab value results to indicate bleeding has occurred or is still occuring.
What is low hemoglobin and hematocrit?
This electrolyte is often elevated in renal failure.
Kayexelate (sodium polystyrene sulfonate) is prescribed to treat this electrolyte imbalance. The medication works by inducing diarrhea/GI loss of potassium.
What is potassium? Hyperkalemia
The nurse examines the patient and notes this heart sound indicating heart failure.
What is a third heart sound? Also known as "S3" or "S3 gallop".
The nurse understands that these vital signs indicate hemodynamic instability in a patient with pneumothorax.
What is low blood pressure (hypotension), tachycardia (high heart rate), and decreased O2 saturation?
The nurse knows that trauma patients are susceptible to many complications including these.
What is compartment syndrome, fat embolism, hypovolemic shock, infection, and neurogenic shock?
The nurse anticipates this lab test must be done to prepare a patient to receive a blood transfusion.
What is a type and screen blood test?
The nurse anticipates this type of monitoring for a patient with hyperkalemia?
What is telemetry monitoring?
The nurse anticipates this may be a side effect of loop diuretics.
What is tinnitus? (ringing in the ears)
What is head of bed 45 degrees and affected side arm above head?
The nurse knows that this medication is the number one priority to be given to a trauma patient to prevent the spread of spinal cord injury.
What is corticosteroids?
The nurse recognizes these steps as part of this process:
Two nurses must perform verification prior to each administration of a blood product. Only 0.9% Normal Saline can be infused with blood products. A Y-type blood administration set is appropriate. A peripheral IV can be used; 18-Gauge or 20-Gauge needle is large enough for rapid transfusion. Blood type compatibility.
What is blood administration protocol?
The nurse will assess this first when a patient on peritoneal dialysis complains of abdominal pain and nausea.
What is the color and clarity of dialysate outflow?
The nurse anticipates these may be side effects of nitroglycerin?
What is headache and low blood pressure?
The nurse will gather these supplies needed for chest tube insertion.
What is sterile personal protective equipment, anesthesia and incision supplies, chest tube and drainage system, occlusive vaseline dressing, and suture materials?
The nurse anticipates repeated use of this scale to determine level of consciousness in a trauma patient.
What is the Glawgow Coma Scale?
The nurse anticipates these signs of clinical improvement in a patient after blood transfusion.
What is improved blood pressure, heart rate, skin color, and respiratory rate?
This is a very common complication of hemodialysis and may require adjustment of hypertension medications.
What is hypotension?
The nurse will anticipate these imaging studies for a patient with heart failure?
What is chest x-ray and echocardiogram?