Shock
A patient develops vasodilation, increased capillary permeability, and worsening hypoxia—this stage of shock is:
What is the progressive stage?
This type of airway adjunct is used when a patient has an intact gag reflex.
What is a nasopharyngeal airway?
This complication results from exaggerated sympathetic response to stimuli below injury level. What is the first intervention for this condition. What are the causes of this condition?
What is autonomic dysreflexia? What is elevating the head of bed? What is bowel and bladder distension, spasticity, pressure ulcers?
A patient with SIADH has a sodium level of 118 mEq/L. the providers order states to increase sodium by 15/hour. What nursing intervention needs to take place.
Question this order, should not exceed 8 per hour.
A patient is experiencing an Addisonian crisis. What is the nurse’s priority intervention?
Administer high-dose hydrocortisone
In septic shock, this volume of crystalloid fluid is initiated within the first hour.
What is 30 mL/kg?
This condition causes decreased tidal volume, increased pressure, and reduced cardiac output due to abdominal pressure.
What is abdominal compartment syndrome?
What are the medications used to treat muscle spasticity in a patient with SCI
Baclofen, dantrolene, diazepam, tizanidine
Which IV fluid is most appropriate for a patient with DI who cannot tolerate oral intake?
D5W or 0.45% saline
"I have an awful toothache right here," a 38-year-old male tells you as he points to his right lower jaw. "I lost my dental insurance, so I haven't seen a dentist for a couple of years." No obvious swelling is noted. Vital signs are within normal limits. Pain 9/10. What ESI level
Level 5
A patient with JVD, hypotension, and clear lungs is most likely experiencing this condition.
What is cardiac tamponade (obstructive shock)?
12.
A trauma patient is:
Priority action?
CT scan
This complication increases risk due to venous pooling and immobility after SCI.
What is deep vein thrombosis (DVT)?
what findings differentiate HHS from DKA
Blood glucose >600 mg/dL
Absence of ketones
Gradual onset
no acidosis
Pin care, assess for infections, assess weights hanging freely off ground, rope intact, dont alter pins if loose - alert doctor
This ventricular assist device complication includes platelet destruction and blood in urine.
What is hemolysis or device-related blood trauma?
A trauma patient has:
Which action is most appropriate regarding NGT placement?
C. Insert orogastric tube instead
A patient with a recent spinal cord injury presents with:
Which condition is most likely?
Spinal shock
what is the management/nursing interventions for a patient with diabetes insipidus
retore circulating fluid volume with rapid fluid administration, PO fluid replacement (if unable to tolerate-IV-hypotonic initally D5W/0.45 NS), adequate I/O, watch for s/s of adequate hydration, pham replace ADH, treat underlying condition (reverse increased ICP)
what patient instruction is correct for Addison’s disease medication management?
Take 2/3 dose in morning, 1/3 in afternoon
A patient with sepsis has received 30 mL/kg fluids. Current findings:
What is the priority action?
B. Initiate norepinephrine infusion
EMS arrived with an unresponsive 19-year-old male with a single self-inflicted gunshot wound to the head. Prior to intubation, his Glasgow Coma Scale score was 3. What ESI level is this
Level 1
A patient presents with:
Another patient presents with:
What is the correct interpretation?
First has neurogenic shock, second has autonomic dysreflexia
What is the population, onset, blood sugar, PH, urine ketones, and serum osmolality of DKA vs. HHS
DKA: population (type 1 DM), onset (rapid <24hrs), Blood sugar (>250), ph (<7.3), urine ketones (present), serum osmolality (300-350).
HHS: population (type 2 DM), onset (gradual, days), Blood sugar (>600), ph (normal), urine ketones (absent), serum osmolality (>350).
1st 48-72 hours = paralytic ileus, needs NGT. Once bowel sounds return and passing flatus, can perform swallow eval. If pass eval, can progress to oral diet. If fail eval, need to insert more permanent tube and start enteral feedings. Bone breakdown causes serum hypercalcemia. High protein/high cal diet d/t energy and tissue repairment