Medications and labs
Before giving IV potassium chloride, what is an essential safety check?
What is verify concentration, dose, renal function, and appropriate IV access; IV potassium must be diluted and administered using an infusion pump
A patient has a BP 82/46, HR 124, cool and clammy skin, and delayed capillary refill. What finding most strongly suggests poor tissue perfusion?
What is cool and clammy skin, and delayed capillary refill
A patient with diabetes is confused, diaphoretic,
shaky, and has a blood glucose of 48 mg/dL. What is
the priority intervention if the patient cannot safely
swallow?
What is administer IV dextrose or glucagon according to protocol, depending on available access and the patient's condition.
What is cardiac output
What is the amount of blood the heart pumps per minute
A patient receiving heparin develops a platelet count that falls substantially from baseline. What should be considered?
What is Heparin-Induced Thrombocytopenia (HIT)
A septic patient remains hypotensive after initial IV crystalloid. What medication is commonly first-line vasopressor?
What is norepinephrine
A patient with DKA has glucose 520 mg/dL, Kussmaul
respirations, and fruity-smelling breath. What is the
first major treatment priority?
What is fluid resuscitation with isotonic IV fluids is a major initial priority.
What two variables determine cardiac output
A patient taking warfarin has an INR of 6.5 and active bleeding. What is the priority?
What is hold warfarn, notify provider, administer reversal (Vitamin K, KCentra)
What is the purpose of monitoring MAP in a critically ill patient?
What is MAP helps assess whether the vital organs are receiving adequate perfusion
A patient with DKA has a potassium of 3.0 mEq/L. The insulin infusion is ordered. What should the nurse recognize before starting insulin?
Insulin will drive potassium into cells and can worsen hypokalemia. Potassium replacement is needed before insulin when K is severely low, per protocol.
What major complication can occur if a PA catheter is improperly managed or manipulated
What is pulmonary artery rupture
a patient on digoxin reports nausea and seeing yellow-green halos. What should the nurse suspect?
What is possible Digoxin Toxicity
A patient with acute heart failure has crackles, severe dyspnea, and SpO2 86%. What is the immediate nursing priority?
Support oxygenation immediately: sit the patient upright, apply oxygen, and rapidly reassess
A patient with SIADH has sodium 118 mEq/L,
headache, confusion, and a seizure. What is the
priority nursing concern?
What is severe acute symptoms can cause cerebral edema and seizures; hypertonic saline may be used in
severe symptomatic cases under close monitoring.
Pt has BP 86/50 , MAP 62, Lactate increasing, urine output decreasing, new confusion. What can be happening
What is poor perfusion
A patient with severe hyperkalemia has peaked T waves on ECG. What mediation is given urgently to stabilize the cardiac membrane?
IV calcium
A patient receiving norepinephrine reports burning at the IV site. What complication is suspected and what is the nursing priority?
A patient with adrenal insufficiency presents with
severe hypotension, weakness, vomiting, and
hyponatremia. What endocrine emergency should be
suspected and what treatment is anticipated?
What is Adrenal crisis (acute adrenal insufficiency). Anticipated treatment includes urgent IV corticosteroids and isotonic fluids, with correction of hypoglycemia/electrolytes as needed
Why does PAWP provide information about the left side of the heart even though the catheter is in the pulmonary artery ?
When the balloon is wedged, pressure is transmitted backward through the pulmonary vasculature to the left atrium