Cardiac/Blood Disorders
In Sickle Cell Disease, the central event that leads to a vaso-occlusive crisis is ...
What is sickling or deoxygenation of RBCs that clump and block small vessels. RX: Remember HOP (hydration, oxygenation and pain managment)
Tachypnea, tachycardia, a cough producing green or rusty colored sputum are expected clinical signs of this condition..
What is pneumonia? RX: if bacterial antibiotics. Before administering antibiotics must obtain sputum culture/blood culture. Encourage incentive spirometer use (10 times every hour while awake), Encourage high fluid intake (2-3 liters per day). Position in High-Fowlers for lung expansion and aspiration precautions.
This severe, sharp and wavy flank pain often radiating to the groin is the hallmark sign of a urinary tract stone.
What is urolithiasis? Stones are composed of calcium oxalate, calcium phosphate, or uric acid. Causes of stones may be dehydration, high protein diet, immobilization leads to hypercalcemia, history of gout leads to uric acid stones, and recurrent UTI's.
Pathological process in Multiple Sclerosis..
What is demyelination of the Central Nervous System (CNS).
Warning: Avoid hot showers, hot tubs, saunas, and excessive exercise in high heat, as heat triggers severe symptom exacerbations
While clients with peripheral venous disease are advised to elevate their legs above heart level to reduce edema, clients with peripheral arterial disease should place their legs in this position to encourage blood flow.
What is dependent or dangling position?
PAD: occlusion of peripheral arteries (most commonly in the legs) caused by atherosclerosis.
Pain pattern Intermittent claudication (pain with walk) Dangling helps pain. (Shiny, hairless pale skin)
A nurse is caring for a client with suspected left-sided heart failure. There are the clinical manifestations the nurse should expect to find...
What is Hepatomegaly (enlarged liver), Dependent edema, and Jugular Venous Distention (JVD)? Rx: ACE inhibitors/ Loop diuretics/Monitoring weight
To optimize lung expansion, promote venous drainage, and prevent tension on the suture line after a thyroidectomy, the nurse positions the client in Semi-Fowler's with their head and neck maintained in this alignment.
What is neutral position. Post operative swelling in neck can quickly compromise the trachea. This position reduces laryngeal edema and hematoma formation. Keep emergency tracheostomy tray/kit at bedside. Calcium gluconate also for s/sx tetany +Troussea's (wrist spasm with BP cuff inflation), + Chovstek's ( facial spasm).
Post-operative abdominal wound has separated and the internal bowels are protruding through the incision. The nurse documents....
What is evisceration? This is a surgical emergency and in order to keep the tissue viable remember to apply moist sterile gauze or towels saturated with warm, sterile 0.9% Normal saline. Never attempt to push the organ back.
A client is admitted with a compound fracture. This complication is monitored for the first 24-48 hours after injury...
What is fat embolism syndrome?
Petechial rash distinguishes a fat embolism from a standard pulmonary embolism (PE)!
This type of adaptive immunity is characterized by the production of B cells and antibodies after exposure to a pathogen?
What is humoral immunity?
B cells differentiate into Plasma cells (which secrete antibodies) and Memory B cells (which store the memory of the antigen for rapid future response).
Delivering high-flow oxygen e.g. 100 % NRB mask to a COPD client can cause this condition.
What is eliminating the client's hypoxic drive to breathe, leading to severe carbon dioxide retention (hypercapnia) and respiratory failure. RX: 1-2 liters nasal oxygen, pursed lip breathing, tripod positioning/small frequent meals, SABA's (albuterol), Inhaled Corticosteroids Budesonide (rinse mouth to prevent oral candidiasis (thrush)
A client presenting with a pH of 7.28, a PaCo2 of 55 mmHg, and an HCO 3 of 24 mEq/L is experiencing this specific acid-base imbalance.
What is respiratory acidosis? Remember this is acid-base imbalance caused by alveolar hypoventilation (retaining too much Co2). RX: Position high-Fowler's. Incentive spirometry. If due to Opioid overdose administer Narcan.
Along with severe, sudden epigastric or left upper quadrant abdominal pain radiating to back, the client presents with nausea, vomiting, absent bowel sounds. And the nurse may observe Cullen's signs (periumbilical bruising( or Grey Turner's sign (flank bruising).
What is pancreatitis? Autodigestion of the pancreas by its own digestive enzymes (primarily trypsin, amylase, and lipase) that become prematurely activated inside the pancreas instead of the duodenum. Top causes are gallstones in biliary tract and chronic alcoholism.
Common in children whose bones are soft and flexible, this type of fracture occurs when one side of the bone bends and the other side breaks.
What is a greenstick fracture?
Neurovascular Checks (The 6 P's):
Always assess distal to the fracture: Pain, Pallor, Pulselessness, Paresthesia (numbness/tingling), Paralysis, and Poikilothermia (cool temperature).
What are nurses primary concerns for cancer patients when they develop myelosuppression (bone marrow suppression).
What is anemia, neutropenia, and thrombocytopenia? (ANT)
Bone marrow suppression is a primary side effect of chemotherapy, radiation therapy, and immunosuppressive medications.
This complication can be seen in Atrial Fibrillation due to blood stasis in the atria.
What is ischemic stroke due to thrombus formation? RX: Thrombolytic TPA/Anteplace/Tenecteplase. Time is brain (3-4.5 hours last known well). Priority action before drug-CT scan.
This progressive lung condition, a subtype of COPD, is characterized by the irreversible destruction of alveolar walls, leading to trapped air and impaired gas exchange.
What is emphysema? Clinical signs: Barrel chest (AP) chest diameter 1:1 instead of 1:2 ratio), Tripod position, clubbing of fingers, Cachexia (weight loss). Drug RX: SABA/ LABA/Steroids. Remember if on steroids taper to avoid Addisonian' like crisis and monitor glucose levels for hyperglycemia, and give with meals to avoid gastric ulcerations.
Dysuria (painful urination), Hematuria (blood in urine) and Urgency are characteristic findings in this condition...
What is a lower urinary tract infection (cystitis)?
Primary Causative Organism: Escherichia coli (E. coli)
This happens to the skeletal muscle when immobilized in a cast...
What is disuse muscle atrophy?
To safely relieve itching under a fiberglass or plaster cast without risking skin breakdown or infection, the nurse instructs the parent of a child with a greenstick fracture to use a hairdryer on cool.
Client with diabetes has a glycosylated hemoglobin (Hb-A1c) level of 8.5%. This value indicates...
What is poorly controlled average blood glucose over the last 3 months.
Unlike fasting blood glucose, the patient does NOT need to fast before an A1c test.
For the first 15 minutes of a blood transfusion, a nurse must stay at the bedside to monitor the patient for this life-threatening type of reaction.
What is acute hemolytic reaction? Absolute know that 2 RN verification order, patient id (using 2 unique identifiers), blood type, Rh factor, expiration date, compatibility, baseline vitals. Start transfusion within 30 minutes of leaving blood bank. Complete transfusion within 4 hours.
In addition to rapid breathing from hypermetabolism, a client in thyroid storm who also has an enlarged thyroid gland (goiter) is at immediate risk for this respiratory emergency due to mechanical compression.
What is tracheal obstruction (or upper airway obstruction)? RX: High flow oxygen. To treat overactive thyroid meds: PTU (propylthiouracil), Methimazole, or Lugol's solution (SSKI potassium iodide). Propranolol controls tachycardia/htn. Once thyroid storm controlled. Emergency thyroidectomy can be scheduled.
Unlike its B and C counterparts, this type of hepatitis never becomes chronic, is spread through the fecal-oral route, and has a highly effective vaccine.
What is hepatitis A?
Pre-icteric (Prodromal): Flu-like symptoms ) before jaundice appears.
Icteric Phase: Jaundice, dark ("tea-colored") urine, clay-colored/pale stools, severe pruritus.
Post-icteric (Convalescent): Jaundice fades, lab values normalize, energy levels gradually return.
Before administering this gold-standard intravenous thrombolytic medication within 3 to 4.5 hours of ischemic stroke onset, the nurse must first rule out a hemorrhagic stroke with a non-contrast CT scan.
What is alteplase (tPA)? Thrombolytic (clot buster)
These drugs block the enzyme system that produces gastric acid and are usually given early morning on an empty stomach.
What are Proton Pump Inhibitors?
Generic Name Ending: "-prazole" (e.g., Omeprazole, Pantoprazole, Esomeprazole, Lansoprazole).