CLINICAL REASONING
A post-op patient suddenly becomes restless, anxious, and SOB. O2 saturation drops from 98% to 89%.
What is the nurse's priority action?
Apply oxygen and assess airway/breathing immediately
During a blood transfusion the patient develops chills and flank pain. What is the nurse's first action?
Stop the transfusion immediately
Order: Vancomycin 1000mg PO
Available: 250mg/5mL
Question: How much will the nurse administer?
20 mL
A manic patient is loud, intrusive and hyperactive. Which intervention is most appropiate?
Set firm limits and reduce stimulations
What is the main link between the nervous system and the endocrine system?
The Hypothalamus
A patient with CHF has crackles, edema, SOB and weight gain. What intervention should the nurse anticipate first?
Administer diuretics and place HOB in high Fowler's position
The nurse notes unilateral leg swelling, warmth, and redness. What complication should the nurse suspect?
Deep vein thrombosis (DVT)
Order: Heparin 7,000 units SQ
Available: 10,000 units/mL
How many mL will the nurse administer?
0.7 mL SQ
A schizophrenic patient states, "The voices are telling me to hurt myself." What is the nurse's priority action?
Assess command hallucinations and ensure safety
A surgical patient with a goiter should have this avoided during physical assessment to prevent further hormone release
What is palpating the thyroid?
A patient with pneumonia suddenly becomes confused. What should the nurse assess first?
Oxygenation status
A patient with a medical history of pulmonary embolism suddenly develops chest pain and dyspnea. What is the priority intervention?
Administer oxygen and notify rapid response team/provider immediately
Order: 1,000 mL 0.9% NS infuse over 8 hours
What is the IV pump rate in ml/hr?
125 mL/hr
According to the DSM-5 a person must experience symptoms of mania for this long to be considered bipolar?
What is 4 to 7 days
Apparent changes of buffalo hump and moon face are associated with this syndrome.
What is Cushing's Syndrome
A post-op patient has absent bowel sounds. What complications may the nurse suspect?
What is a Paralytic ileus
During neuro assessment, a patient has unequal pupils and confusion. What should the nurse suspect?
Stroke or Increased intracranial pressure (ICP)
Order: Dopamine 400mg in 250 mL NS, infuse at 10 mL/hr
How many mg/hr is the patient receiving?
16 mg/hr
This act, signed into law, ensured that mental health services are covered by insurance.
What is the Affordable Care Act (ACA)
What are 2 hormones released by the adrenal glands when danger occurs?
Epinephrine and Norepinephrine
A patient with NG tube suction has muscle weakness and dysrhtymias. What electrolyte imbalance should the nurse suspect?
Hypokalemia
Patient reports chest pain radiating to the left arm, nausea and diaphoresis. What is the nurse's priority action, apply top priorities?
1. Assess vital signs
2. Obtain ECG (EKG)
3. Administer Oxygen
4. Notify provider
Lispro insulin 15 units is given SQ at 0730. When should the nurse monitor most closely for hypoglycemia?
Approximately 0830-0930
This is the best thing to do if your daughter's friend makes you promise to keep their intent to harm themselves a secret.
What is break the promise and tell a trusted adult
This condition occurs when the body produces too much antidiuretic hormone.
What is SIADH (Syndrome of Inappropriate Antidiuretic Hormone... ADH/vasopressin)
causing excessive water retention, leads to hyponatremia.