Meds
Once heparin is discontinued with suspected HIT, which medication can be expected?
Argatroban
The client arrives with burns to the face and torso, what is the nursing priority?
Airway & breathing!
The nurse suspects the client who is on a heparin drip has HIT related to todays lab work. What is the priority intervention?
Stop the heparin drip!
List 4 cues of hepatic encephalopathy
Lethargy
Asterixis
Confusion
Change in gait
etc.
Who is most likely to be diagnosed with HHS?
non-compliant type 2 diabetics
What classification of medication can be used to manage pheochromocytoma?
vasodilators
What IVF does the nurse anticipate starting all burn fluid resuscitation with?
After 24 hours what would the IVF be switched to?
Always start with LR
After 24 hours it is common to move to D5W
The client with a reduced platelet count should be on what restricitons?
Bleeding risk!
Soft bristled tooth brush
No razor
Fall risk, assistance with activity
etc.
After the nurse assists with a paracentesis related to ascites, what orders can the nurse anticipate being palced?
BP monitoring
measure abdominal girth
infuse albumin
The client with SIADH gained 8kg in 4 days. What is the priority nursing hypothesis?
a: fluid volume overload
b: impaired breathing
c: electrolyte imbalance
d: knowledge deificit
B! That is 13 pounds in 4 days! Are they breathing ok with all that extra volume?
What type of insulin can be used to manage both DKA & HHS in the in-patient setting?
regular insulin IV infusion
The client arrives with cherry red skin, singed nasal hair and a hoarse cough. What interventions does the nurse anticipate?
Place on 100% oxygen via non-rebreather
Consider emergency intubation
Which lab is most indicative of DIC?
increased d-dimer
Where does the nurse assess for cullens and turner sign?
Cullen = around the umbilicus
Turners = retroperitoneal area
list 3 cues for DKA
kassmual respirations
sweet smelly breath
mental status changes
hyperglycemia
increased thirst
etc.
What medication can be administered to lower ammonia?
lactulose
What is the desired urine output in the first 24 hours following electrical shock?
50-75mL/hr
List 4 cues of DIC
bleeding from IV sites
Blood in urine and/or stool
confusion
bruising
mottling/changes in perfusion
petechia
etc.
The client is suspected of having an acute GI bleed, what are additional cues that nurse would assess for?
Tachycardia
Hypotension
Impaired perfusion
signs of shock etc.
Which endocrine disorder has the following;
•Hypernatremia
•Urine Osmolality LOW
•Serum Osmolality HIGH
•Low levels of ADH in the plasma
Diabetes Insipidus
Which medication can be used with suspicion of esophagel varices with increased portal pressure?
Octreotide
List 4 considerations for burn dressing changes.
Increase room temp
PPE (for staff)
body image
educate the client on steps
pre-medicate
etc.
Which lab are we most concerned with for blood loss?
hemoglobin
Which electrolyte are we most concerned with for pancreatitis?
calcium!! HYPOcalcemia
Which electrolyte do you want to monitor with DKA?
potassium