Fluid & Electrolyte
This electrolyte imbalance, frequently caused by loop diuretics or NG tube suctioning, presents with prominent U waves on an EKG, muscle weakness, and cramps.
What is Hypokalemia?
This lethal cardiac rhythm features a chaotic, wavy baseline with no identifiable P waves, QRS complexes, or T waves, requiring immediate defibrillation.
What is Ventricular Fibrillation (V-Fib)?
This tactile assessment finding is expected when palpating the chest wall of a patient with a large pneumothorax or subcutaneous emphysema, often describing a "rice krispies" cracking sensation under the skin.
What is Crepitus?
This severe complication of Type 1 Diabetes presents with metabolic acidosis, Kussmaul respirations, ketones in the urine, and a fruity odor to the breath.
What is Diabetic Ketoacidosis (DKA)?
his medication is the standard antidote kept at the bedside to reverse respiratory depression caused by opioid toxicity.
What is Naloxone (Narcan)?
This is the most critical assessment for a nurse to perform hourly when administering an intravenous infusion of 3% Normal Saline to a client with severe hyponatremia.
What is lung sounds for fluid overload?
This type of shock is uniquely characterized by bradycardia, hypotension, and warm, dry skin due to a loss of sympathetic nervous system tone.
What is Neurogenic Shock?
Interpret these ABG results: pH 7.31, PaCO2 52 mmHg, HCO3 24 mEq/L.
What is Uncompensated Respiratory Acidosis?
This endocrine emergency presents with extreme hypothermia, bradycardia, hypotension, non-pitting generalized edema, and respiratory depression.
What is Myxedema Coma?
This laboratory test is specifically monitored to adjust the dosing of an intravenous continuous infusion of Unfractionated Heparin.
What is activated Partial Thromboplastin Time (aPTT)?
A client with thyroidectomy notes tingling around the mouth (perioral numbness) and a positive Trousseau’s sign, indicating this specific electrolyte deficiency.
What is Hypocalcemia?
This classic triad of signs—hypotension, jugular venous distention (JVD), and muffled heart sounds—indicates cardiac tamponade.
What is Beck’s Triad?
This hallmark clinical sign differentiates Acute Respiratory Distress Syndrome (ARDS) from standard hypoxemic respiratory failure, where oxygen saturation fails to improve despite increasing levels of supplemental oxygen.
What is Refractory Hypoxemia?
This life-threatening crisis is marked by profound watery diarrhea, massive dilute urine output (low urine specific gravity < 1.005), and severe hypernatremia due to a lack of Antidiuretic Hormone (ADH).
What is Diabetes Insipidus (DI)?
This critical assessment must always be completed immediately before administering a dose of the positive inotrope Digoxin, with the medication held if the value is below 60.
What is checking the apical pulse for one full minute?
This life-threatening electrolyte shift is a primary concern during the first 24 to 48 hours of the emergent phase of a massive major burn injury.
What is Hyperkalemia?
This is the immediate first-line drug therapy and route of choice for a patient experiencing systemic anaphylactic shock.
What is Intramuscular (IM) Epinephrine?
The nurse notes continuous bubbling in the water seal chamber of a client's closed chest drainage system, identifying this system issue.
What is an air leak?
During the oliguric phase of Acute Kidney Injury (AKI), the nurse expects these two primary serum waste products to rise alongside a precipitous drop in urine output.
What are Blood Urea Nitrogen (BUN) and Creatinine?
This medication is administered intravenously to stabilize the myocardial cell membrane and prevent lethal ventricular arrhythmias in a patient with severe hyperkalemia.
What is Calcium Gluconate (or Calcium Chloride)?
A patient presents with Chvostek’s sign, hyperactive deep tendon reflexes, and ventricular arrhythmias; correcting calcium levels has failed, pointing to a deficiency in this co-dependent electrolyte.
What is Hypomagnesemia?
This hemodynamic profile—low cardiac output, elevated pulmonary artery wedge pressure (PAWP), and high systemic vascular resistance (SVR)—defines this specific classification of shock.
What is Cardiogenic Shock?
A patient on a mechanical ventilator has a sudden drop in oxygen saturation, and the high-pressure limit alarm sounds; this nursing action must be performed first if a quick check reveals a kinked tube isn't the issue.
What is auscultate lung sounds and suction the airway (or bag the patient if disconnected/failing)?
This syndrome, often secondary to small cell lung cancer, results in excessive ADH secretion, fluid retention without edema, hyponatremia, and concentrated urine.
What is Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
This severe condition, marked by muscle rigidity, hyperthermia, tachycardia, and metabolic acidosis, is a life-threatening reaction to volatile inhalational anesthetic agents and requires treatment with Dantrolene
What is Malignant Hyperthermia?