SEPSIS/SHOCK
Urinary, Respiratory, GI
When assessing a cardiac rhythm, what do you want to first determine
If it is regular or irregular
What are the two types of dialysis?
Hemodialysis and Peritoneal Dialysis
NIHSS
Type of medication you give for a patient with a pulmonary emobolism
Anticoagulants
Goal for MAP
>65
A normal appearing beat on the monitor that occurs earlier than expected
PAC- Premature atrial complex
For a patient with an AKI, which laboratory result would cause you the greatest concern?
A. K 5.9
B. BUN 25
C. Sodium 144
D. pH 7.5
A. K. 5.9
**IT CAN CAUSE LIFE THREATENING DYSRHYTHMIAS**
Three primary signs that indicate increased ICP
Cushings Triad (increased systolic BP, decreased pulse, decreased respirations)
Risk factors for a pulmonary embolism
Oral contraceptives, long term immobility, pregnancy, tobacco use, surgery, long bone fractures, cancer
Sepsis induced hypotension despite adequate fluid resuscitation
Septic Shock
Nursing interventions for dilated cardiomyopathy
- Monitor cardiac output (blood pressure, heart rate, edema, peripheral pulse, I&O)
- Pain management
- Energy conservation
- Plan for interventions based on origin (LVAD, Pacemaker, ACID etc)
- Monitor for signs of heart failure
- Fluid restrictions
What are signs and symptoms of renal transplant rejection?
Temperature >100, pain to grafted kidney, 2-3lbs of weight gain in 24 hours, malaise, elevated BUN and Creatinine
Two types of spinal cord injuries and their differences
Complete: No sensory or motor function is preserved in sacral segments S4-S5
Incomplete: Preservation of sensory or motor function below the level of injury, including the lowest sacral segments
Which of the following indicates that a patient with pneumonia is responding to antibiotics?
A. Cough, clear sputum, Temp 99, 96% on RA
B. Wheezing, O2 2L NC, RR 26, no SOB or chills
C. Clear lung sounds, Temp 99, O2 2L NC, yellow sputum
D. Fatigued, RR 28, audible breath sounds
A. Cough, clear sputum, temp 99, 96% on RA.
The type of shock where fluid resuscitation is most important
Hypovolemic
Atrial dysrhythmia has a "saw tooth" pattern
Atrial Flutter
The nurse is caring for a 70 year old male who just had coronary artery bypass graft surgery 3 weeks ago. During the oliguric stage of an acute kidney injury, what action would be appropriate to include in the nursing plan of care?
A. Provide foods high in potassium
B. Restrict fluids based on urine output
C. Monitor output from peritoneal dialysis
D. Offer high protein snacks
B. Restrict fluids based on urine output
Nursing Interventions for monitoring ICP
Elevate head of the bed, oxygen saturation >94%, maintain head midline, avoid sudden hip or neck flexion, keep lights low, monitor vital signs.
Medications that relax smooth muscle and help the upper airway
Bronchodilators
A patient is admitted to the ED after sustaining abdominal injuries and broken femur from an MVC. The patient is pale and diaphoretic. Vital signs are as followed:
Temp 98
HR: 130
RR: 34
BP: 70/42
What type of shock is this patient in
Hypovolemic Shock
A. It is uncomfortable for the client giving them a sense of impending doom.
B. It produces a high cardiac output that quickly goes to cerebral ischemia
C. It is almost impossible to convert to normal sinus rhythm
D. It can develop into ventricular fibrillation at any time.
D. It can develop into ventricular fibrillation at any time.
Skin Integrity: keeping skin clean to relieve itching/dryness, creams as needed, oatmeal baths
Prevent Constipation: High fiber diet, stool softeners, increase activity as tolerated
Safety: Monitor patient's gait, analgesics as ordered for pain and cramps
Medications used for a TBI
Mannitol and 3% Saline
The most common early manifestation of ARDS a nurse may see are:
A. Dyspnea and tachypnea
B. Cyanosis and apprehension
C. Respiratory distress and frothy sputum
D. Bradycardia and Increased work of breathing
A. Dyspnea and Tachypnea