Electrolytes
A patient has a sodium level of 128 mEq/L. What electrolyte imbalance is present?
What is hyponatremia?
A patient has intact skin over the sacrum with persistent redness that does not blanch when pressed. What stage is this pressure injury?
What is Stage 1?
A COPD patient develops a barrel-shaped chest because of this chronic change in the lungs.
What is air trapping/hyperinflation?
pH 7.30, PaCO₂ 52, HCO₃⁻ 24
What is respiratory acidosis?
A trauma patient has multiple rib fractures. During inspiration, part of the chest wall moves inward instead of outward. What condition is this?
What is flail chest?
A patient taking a loop diuretic develops weakness and muscle cramps. The potassium level is 2.9 mEq/L. What imbalance should the nurse identify?
What is hypokalemia and Hypomagnesemia?
A patient has partial-thickness skin loss with a shallow, pink/red wound bed. Adipose tissue is not visible. What stage is this?
What is Stage 2?
A patient suddenly develops severe dyspnea and absent breath sounds on the right side. What emergency should the nurse suspect?
What is a right-sided tension pneumothorax?
pH 7.50, PaCO₂ 30, HCO₃⁻ 24
What is respiratory alkalosis?
A hospitalized patient suddenly develops shortness of breath, tachycardia, chest pain, and low oxygen saturation. What life-threatening condition should the nurse suspect?
What is a pulmonary embolism?
A patient reports numbness and tingling and has positive Chvostek and Trousseau signs. Which electrolyte is most likely low?
What is hypocalcemia?
A pressure injury has full-thickness skin loss, and adipose tissue is visible, but muscle, tendon, and bone are not exposed. What stage is this?
What is Stage 3?
This emergency procedure is performed to rapidly release trapped air in a tension pneumothorax.
What is needle decompression?
pH 7.28, PaCO₂ 40, HCO₃⁻ 18
What is metabolic acidosis?
A patient has a large blood clot blocking blood flow. This procedure physically removes the clot from the blood vessel. What is the procedure called?
What is a thrombectomy?
The cardiac monitor shows tall, peaked T waves in a patient with renal failure. Which electrolyte abnormality should the nurse suspect first?
What is hyperkalemia?
A pressure injury has full-thickness skin and tissue loss with exposed bone, tendon, or muscle. What stage is this?
What is Stage 4?
A severe asthma attack that does not respond to usual treatment and can lead to respiratory failure is known as this.
What is status asthmaticus?
pH 7.48, PaCO₂ 40, HCO₃⁻ 32
What is metabolic alkalosis?
A critically ill patient's heart and/or lungs can no longer adequately oxygenate the blood. This machine temporarily removes blood, adds oxygen, removes CO₂, and returns the blood to the patient. What treatment is this?
What is ECMO (extracorporeal membrane oxygenation)?
A patient has a magnesium level of 3.4 mg/dL, decreased deep tendon reflexes, bradycardia, and respiratory depression. Which medication should the nurse anticipate administering?
What is calcium gluconate?
A patient's pressure injury is completely covered by slough and eschar, preventing the nurse from determining the depth of tissue damage. How should this wound be classified?
What is an unstageable pressure injury?
This procedure uses a needle or catheter to remove fluid from the pleural space for diagnosis or symptom relief.
What is thoracentesis?
pH 7.36, PaCO₂ 52, HCO₃⁻ 30
What is fully compensated respiratory acidosis?
ARDS Impact in overall health?
Psychosocial:
•Activity restrictions may affect the client’s ability to participate in social or physical activities.
•Client must emotionally acknowledge the condition.
•Client must demonstrate learning readiness.
•There may be financial issues associated with medical care of respiratory failure.
•Client safety (smoking with home oxygen therapy)
Nursing interventions:
•Enteral nutrition
•Mechanical ventilation
•Antibiotics if necessary
Triggers:
•Sepsis
•Pulmonary embolism
•Trauma
Evaluating the ARDS Severity
•Level of consciousness
•Respiratory rate
•Skin color